Effect of synthetic protease inhibitor on histologic changes and free radical activity in hamsters with pancreatic cancer

To investigate the effects of synthetic trypsin inhibitors on pancreatic cancer, camostat (FOY-305) was administered orally to hamsters with experimental pancreatic cancer induced by diisopropanol nitrosamine (DIPN). The effect of free radicals on carcinogenesis was examined by measuring the tissue levels of the scavengers superoxide dismutase (SOD) and glutathione peroxidase (GSX-Px), and pancreatic tissues were examined histologically. Cancers developed in all hamsters that survived 24 weeks in the DIPN group and the FOY group, but 80% of the cancers in the DIPN group were tubular adenocarcinomas, and 91% of those in the FOY group papillary adenocarcinomas. The SOD activity in the DIPN group was significantly lower in the cancerous area and the borderline region than in the non-cancerous region and normal tissue. SOD activity in the cancerous and borderline regions was higher in the FOY groups than in the DIPN group. GSH-Px levels in the borderline and non-cancerous regions were significantly higher in the FOY group than in the DIPN group. These results suggest that the synthetic protease inhibitor slows the progress of pancreatic cancer by its free radical scavenging activity.

Nuclear DNA content as a prognostic predictor in carcinoma of the pancreas

Eighty-six patients with carcinoma of the pancreas were studied retrospectively. Paraffin-embedded specimens and flow cytometry were used to evaluate the accuracy of the measurement of nuclear DNA as a predictor of the postoperative prognosis. From the series of 86 patients, 72 with a diagnosis of tubular adenocarcinoma (Japanese classification) were selected, and their DNA ploidy pattern and clinical and pathological features were correlated; 52.3% of the 86 patients and 52.8% of the 72 tubular adenocarcinoma patients showed DNA aneuploidy. Histological examinations of the tubular adenocarcinomas showed 42.9% DNA aneuploidy in well differentiated, 56.8% in moderately differentiated, and 71.4% in poorly differentiated types. The DNA ploidy showed a statistically significant positive correlation with the T category. The presence or absence of retroperitoneal invasion was thought to be the most important prognostic factor. Cumulative survival rates showed that the prognosis for patients with retroperitoneal invasion and DNA aneuploidy was significantly worse than for those with DNA diploidy or those without retroperitoneal invasion.

The role of the interleukin-2 (IL-2)/IL-2 receptor pathway in MRL/lpr lymphadenopathy: the expanded CD4-8- T cell subset completely lacks functional IL-2 receptors

Autoimmune MRL/MP-lpr/lpr (MRL/lpr) mice spontaneously develop a systemic lupus erythematosus-like disease accompanied by a profound lymphadenopathy that consists of CD4-8-B220+ alpha beta T cells. By the use of cross-linking experiments with radiolabeled interleukin-2 (IL-2), these abnormal T cells have been reported to constitutively express the IL-2 receptor beta chain (IL-2R beta), a signal transducing component of IL-2R, in the absence of the alpha chain (IL-2R alpha). To critically reevaluate the role of the IL-2/IL-2R pathway in the pathogenesis of lymphadenopathy we examined expression of the IL-2R alpha and IL-2R beta in MRL/lpr mice by 125I-IL-2 binding analysis and also by flow cytometric analysis using monoclonal antibodies against each component of the receptor. We found that, contrary to the previous report, the CD4-8-B220+ alpha beta T cells in lymph node (LN) of MRL/lpr mice were negative for both IL-2R alpha and IL-2R beta expression. The lpr liver CD4-8-B220+ alpha beta T cells that had been implicated in the genesis of these abnormal LN T cells were also negative for IL-2R beta expression. Therefore, our results indicate that the IL-2/IL-2R system plays little role, if any, in the expansion of abnormal CD4-8-B220+ alpha beta T cells in MRL/lpr mice.

[Dumbbell cervical neurinomas with subcutaneous extension: report of two cases]

Two cases of dumbbell cervical neurinomas with massive subcutaneous extension were reported. The first case was A 30-year-old woman who was admitted to our hospital because she had been aware of a left lateral cervical subcutaneous mass and was suffering from shoulder dullness. On admission, neurological examination revealed hypesthesia to touch and pain in the segmental area of C4, and hyperreflexia in the left biceps and patellar tendon reflexes. Plain X-ray showed enlargement of the left C3/4 intervertebral foramen. CT scan, post-myelogram CT and MRI demonstrated a dumbbell shaped tumor at the level of C3-4. Angiogram showed an anterior shift of the left vertebral artery (VA) and tumor stain. Temporary occlusion of the left VA by a balloon catheter was performed leaving no neurological deficits. The second case was a 36-year-old woman who had been aware of a left lateral cervical subcutaneous mass. She complained of shoulder pain and finger clumsiness. On admission, neurological examination revealed weakness of the left deltoid muscle, hypesthesia in the segmental area of C3-4 and exaggeration of all deep tendon reflexes in the left-side extremities. Plain X-ray showed enlargement of the C2/3, C3/4 and C4/5 intervertebral foramina. CT scan, post myelogram CT and MRI demonstrated a dumbbell shaped tumor at the level of C2-5. Angiogram showed an anteromedial shift of the left VA and tumor stain. Temporary occlusion test of the left VA by a balloon catheter was performed with negative results. In each case two-stage operations were undertaken with excellent results.(ABSTRACT TRUNCATED AT 250 WORDS)

[Long-term follow up of trigeminal neuralgic patients treated by retrogasserian rhizotomy or by microvascular decompression]

The authors studied the long-term follow up of trigeminal neuralgic patients treated by retrogasserian rhizotomy with anhydrous glycerol injection (GI) or by microvascular decompression (MVD) and compared the satisfaction rates between them. Since 1983, 67 patients had been treated either by GI or MVD. The authors analyzed the results of the treatment by the method of questionnaire. Fifty-two patients of these 67 answered the questions, on which the present analysis was based. GI group consisted of 27 patients and MVD group 29 patients. The average follow-up period was 30.9 months in GI group (maximum follow-up: 84 months) and 50.9 months in MVD group (maximum follow-up: 95 months), respectively. The technique of GI used was Härtel's method with cisternography of Meckel's cave. The operations of MVD were performed by J.H. and A.K.. One patient out of 29 failed to be treated by MVD and two recurred within one year. On the other hand, 2 patients out of 27 failed to be treated by GI and 11 recurred. The recurrence was seen earlier in patients who had undergone GI, while one patient recurred the neuralgia at 76 months later. The recurrence rate in patients treated by MVD is 7.0% at 95 months, while that by GI is 49.0% at 84 months based on Kaplan-Meier survival analysis. The pathogenesis of trigeminal neuralgia is speculated to be an emphatic conduction caused by segmental demyelination and artificial synapse formation at the junction of central and peripheral myelin. The factors of this demyelination may be multiple sclerosis, basilar impression, aneurysm, arteriovenous malformation, atheroscleroses and natural aging.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical features of intradural neurinomas in the cauda equina and around the conus medullaris

In this contribution the clinical features of eleven patients suffering from a neurinoma in the cauda equina and around the conus medullaris are analysed. Because of the relative mobility of the roots and the wide space in the spinal canal, tumours arising in the cauda equina or around the conus medullaris can become larger than any other spinal tumours. Lumbago was the predominant symptom as the initial complaint. Nocturnal pain relieved by walking was noticed in one patient. Two cases showed spontaneous remission and relapse. Multiple tumours were found in 6 cases (55%). Macroscopic cyst formation was found in 5 cases (45%). Among the eleven patients, total removal of the tumour, including the involved root, was performed in ten. The numbers of the resected nerve roots were one root in 6 cases, two roots in 2, and three roots in 2. Only one patient showed postoperative slight weakness of the leg.

[Intraparenchymal granulocytic sarcoma in acute monocytic leukemia; case report]

Granulocytic sarcoma of the parenchyma of the brain present in a patient with acute monocytic leukemia, and its unusual course during treatment, is described. Four years after diagnosis of acute monocytic leukemia, a 24-year-old man developed severe headache during its remission period. The CT scan showed large intraparencymal mass in the right frontal lobe, which was partially removed and diagnosed as granulocytic sarcoma. Following the operation, radiation in total dose of 35.5 Gy was given to the whole brain, and there was also left intraventricular administration of methotrexate (MTX) and cytosine arabinoside (ara-C). The treatment resulted in the complete disappearance of the intraparenchymal mass apart from small calcifications. Five months later, the patient redeveloped severe headache with consciousness disturbance. CT scan revealed marked swelling in the left cerebral hemisphere with irregular contrast-enhanced areas. The patient died of brain herniation in spite of conservative therapy. Photomicroscopic findings of the left cerebral hemisphere proved the presence of "disseminated leukoencephalopathy" and the absence of tumor cells. On the other hand, the right frontal lesion consisted of no tumor cells but scar tissues. This unusual feature of the CT scan in the terminal stage might be caused by combination with the effect of highly concentrated MTX in the left cerebral hemisphere because of the increased permeability of the ependym and the relatively high radiosensitivity in the non-affected left cerebral hemisphere.

[A case report of cervical disc hernia presenting fecal incontinence evoked by walking; spinal intermittent rectal dysfunction]

Intermittent clinical manifestations, the representative one of which is claudication, can be classified into two types; neurogenic and vasculogenic. Although cauda equina lesions are well known as a neurogenic cause, spinal disorders, especially cervical or thoracic cord lesions, have been paid more attention to by several authors recently. We encountered a 42-year-old man with cervical soft disc hernia and ossification of longitudinal ligament, who showed intermittent rectal dysfunction evoked by walking. This peculiar clinical manifestation successfully disappeared after surgical decompression of the spinal cord. Such an interesting case has not been reported in the world literature. The patient was admitted because of numbness in both hands. Neurological examinations on admission showed neither motor weakness nor abnormally increased tendon reflex. Hypesthesia and hypalgesia were noticed below the Th4 dermatome on both sides. Adding to those symptoms, he complained of fecal incontinence evoked by walking 100 meters. This rectal dysfunction became gradually worse. At last he showed fecal incontinence after walking only 10 meters. This was ten days after his admission. Myelogram and computed tomographic scan revealed a cervical soft disc hernia at the C5/6 level and findings of OPLL at the C5 and C6 level. Anterior cervical approach for OPLL and soft disc was used for bone graft insertion from the C4 to the C7 vertebral body. The rectal dysfunction completely disappeared after the operation. The possible mechanisms of intermittent rectal dysfunction evoked by walking were discussed.

[Clinical experience with recently produced devices for use in spinal surgery]

The authors reported their clinical experience with devices, which have been recently introduced for spinal surgery. The main roles of such devices are to correct malalignment of the spine and stabilize the spinal instability. Although Harrington's device has been widely used since 1962, its use is gradually decreasing due to its having several weak points, such as its low resistance to distorting forces and its imperfect ability to correct malalignment of the spine. In the present manuscript, the authors describe clinical experience with three kinds of spinal devices. They are Steffee's transpedicular screw for 5 cases of lumbar spondylolisthesis, Roosen-Trauschel compression clamp for 2 cases of atlanto-axial dislocation and Kaneda's device for one case of metastatic T-11 tumor. Good fixation was obtained in 4 cases using Steffee's devices. The injury of the nerve root is one of the most serious disadvantages in this device. Although Roosen-Trauschel compression clamp needs improvement in some aspect, it was able to bring about good stabilization without using sublaminar wiring, which may be a dangerous procedure in the cervical region. Kaneda's device seemed to be useful for the thoracolumbar lesion. Although it needs a relatively radical approach, such as thoracotomy, Kaneda's device brought about good stabilization and corrected the kyphosis. The devices, which are described in the present manuscript, will probably play important roles in spinal surgery in the future.

[Successful surgical treatment of subdural hematoma following mitral valve replacement]

A 56-year-old woman, followed after mitral commissurotomy, was admitted to the hospital because of congestive heart failure of NYHA IV. Cardiac catheterization demonstrated severe MSR and TR. MVR using a SJM prosthetic valve and TAP with DeVega's method were performed under cardiopulmonary bypass with moderate hypothermia (25 degrees C). Postoperative hemodynamic condition was good with a uneventful convalescence. But disturbance of consciousness was seen with gradual deterioration and anisocoria developed on the 4th postoperative day. CT scan revealed a subdural hematoma in the right frontal and parietal region. Irrigation of the hematoma was performed immediately by neurosurgeons. She resumed full consciousness and was discharged from the hospital without any sequelae on the 49th postoperative day. The importance of the early diagnosis and the immediate treatment for the subdural hematoma following open heart surgery was emphasized.

[Two cases of von Recklinghausen's disease with multiple brain and spinal tumors]

The authors reported two cases of von Recklinghausen's disease with multiple brain tumors and multiple spinal tumors. The first case, a 21-year-old man who had a past history of optic gliomas was admitted because of gait disturbance. Computed tomography (CT) and magnetic resonance imaging (MRI) showed calcification of the basal ganglia, bilateral C-P angle tumors, cystic cerebellar tumor and arachnoid cyst in the quadrigeminal cistern. Myelography and MRI revealed multiple spinal tumors. Surgical management was performed and cerebellar tumor was histologically confirmed to be a pilocytic astrocytoma. Spinal tumors were also astrocytomas. The second patient, a 56-year-old woman suffered from right iliac pain, right hemiparesis and motor aphasia. CT revealed two round tumors in the left cerebral hemisphere and bilateral C-P angle tumors. Myelography and MRI demonstrated multiple intradural-extramedullary spinal tumors. Histologically, supratentorial tumors were transitional meningiomas and spinal tumors were neurinomas. It is well known that von Recklinghausen's disease is often associated with brain or spinal tumors. But, in the literature, only 22 cases of von Recklinghausen's disease combined with multiple brain tumors with different histological types and multiple spinal tumors have been reviewed. With our two cases, the average age of these 24 cases was 28.6 years old, nine cases were male and 15 cases were female. All patients had C-P angle tumors and 23 cases were combined with intracranial meningiomas. In this paper, the clinical features and diagnostic aspects were discussed.

Partial portal arterialization for the prevention of massive liver necrosis following extended pancreatobiliary surgery: experience of two cases

Massive liver necrosis, which is a severe and highly fatal complication after extended pancreatobiliary surgery, may occur due to an interruption of the hepatic arterial flow caused by such events as an excision of the hepatic artery invaded by cancer, a ligation of the postoperatively ruptured hepatic artery, or a thrombotic obstruction of the reconstructed hepatic artery. In order to improve this ischemic state of the liver, we have performed a partial arterialization of the portal vein by making an arteriovenous shunt at the mesenteric vascular branches in two cases. Although a sufficient pathophysiological investigation could not be fully conducted, partial portal arterialization was considered to be effective in one patient, while no clinically noticeable adverse effects were revealed in the other patient.

[Bilateral aneurysms of extracranial internal carotid arteries. Case report]

A 52-year-old male was admitted because of right hemiparesis. Computed tomography scan showed a low-density area in the basal ganglia on the left side. Left carotid angiography showed an aneurysm of the extracranial internal carotid artery at the level of the C1-C2 vertebral body. Right carotid angiography also showed an aneurysm of the extracranial internal carotid artery. Because there were neither steno-occlusive changes in the intracranial vessels nor abnormality in the heart, the right hemiparesis seemed to be due to embolism from the extracranial aneurysm. Aneurysmectomy and end-to-end anastomosis of the left internal carotid artery were performed. Extracranial carotid aneurysms are rare conditions. In surgery on these aneurysms, ischemic changes of the brain during arterial clump must be detected and treated. Hypothermia, induced hypertension, and/or internal shunting have been used during arterial clump. The pathogenesis, symptoms, prognosis, and surgical treatments of these aneurysms are discussed.

[Ossification of the thoracic ligamentum flavum presenting with intercostal neuralgia. Case report]

A 46-year-old female was admitted complaining of progressive, severe girdle pain consistent with the left Th3 dermatome. Neurological examination on admission revealed dysesthesia and radiating pain in the left Th3 territory. Plain X-rays and tomograms of the thoracic spine revealed a beak-like bony excrescence arising from the lamina and projecting moderately to the Th3/4 intervertebral foramen, suggesting ossification of the thoracic ligamentum flavum (OYL). Myelography showed the dural sac compressed from laterally just below the left Th3 pedicle, which suggested that the Th3 nerve root was compressed by the OYL. After Th3 nerve root decompression through hemilaminectomy and foraminotomy, the girdle pain disappeared. OYL is known to cause thoracic radiculomyelopathy, but presentation with intercostal neuralgia only is very rare. The authors review the literature and stress the importance of myelography for diagnosis.

[Clinical analysis of ossified thoracic ligaments and thoracic disc hernia]

Thoracic lesions present several clinical problems, particularly in their diagnosis and treatment, compared with cervical or lumbar lesions. Since 1983, 18 cases of thoracic space lesions, excluding spinal tumors or trauma have been experienced: nine cases of ossification of yellow ligament (OYL), five of ossification of posterior longitudinal ligament (OPLL), and four of disc hernia (DH). In these 18 patients, problems of clinical manifestations, neuroradiological examination, and surgical approaches are analyzed and discussed. As clinical manifestations, there was a preponderant occurrence in males in the OYL group, while in the OPLL group all the patients were females. OYL and DH occurred at lower thoracic levels. Thirteen of the 18 patients showed combined lesions either in the cervical or in the lumbar regions, such as cervical OPLL, cervical spondylosis, lumbar DH, and lumbar canal stenosis. In the neuroradiological examinations diagnosis of the upper thoracic lesions was difficult. Computed tomography (CT) scan with intrathecal metrizamide injection seemed essential for examination of ossified thoracic lesions. However, because CT imaging of the entire spine is impractical, efficient use of this examination requires previous localization of the offending vertebral level from either the neurological findings or other neuroradiological examinations such as myelography. Magnetic resonance imaging seemed most useful for ruling out the thoracic compressing lesions. As for surgical approaches, posterior decompression was effective for OYL and the anterior approach was useful for OPLL and DH. In patients with "tandem lesions," neurological and neuroradiological findings played an important role in deciding the responsible site.

[Clinical analysis of 270 cases of microsurgical lumbar discectomy]

Since 1983, the authors encountered 270 cases of lumbar disc hernia, which were operated on with the microsurgery. In the present study, the operative procedures were described and the results, especially the results of the reoperations were examined. Good results were obtained in 252 patients (93%). In nine patients, some kind of lumbago continued, which required other treatments, such as epidural block (3.3%). Reoperations were performed in nine patients (3.3%). In lumbar discectomy, extent of removal of the bony structures and the disc material seemed important. In "microlumbar discectomy", which was advocated by Williams, only the flavectomy with no bony structure removal was performed. In this procedure, discectomy is limited to the protruded disc material. On the contrary, some authors, who also adopt microsurgical lumbar discectomy as Wilson and Hudgins do, perform subtotal removal of the disc material with removal of some bony structures. In the present series, microsurgical lumbar discectomy following the procedures advocated by Wilson et al was performed. Reoperations after lumbar discectomy have been reported after all kinds of operations. In the present series, the rate of reoperation was 3.3%. As to the reasons for reoperations, true recurrence of disc hernia was the most prevalent. The hernias recurred at the same level and on the same side. Adhesion or fibrosis around the nerve root also played an important role. From the results of the present study, microsurgical lumbar discectomy with good illumination and high magnification has proved to bring satisfactory results. Recurrence, however, can occur after this procedure, so further inventions are required to ensure more satisfactory results.

Complete remission of metastatic teratoma from malignant testicular tumor using salvage chemotherapy with VP-16 (etoposide), CDDP, and ACNU--case report

A 26-year-old male with an intracranial teratoma, metastasizing from a testicular yolk sac tumor refractory to cis-diamminedichloroplatinum (CDDP), vinblastin, and bleomycin (PVB) therapy, was successfully treated with a combination of etoposide (VP-16), CDDP, and ACNU (salvage chemotherapy). Emergency surgery for subcortical hemorrhage discovered the metastasis, diagnosed as a yolk sac tumor. CDDP chemotherapy failed to prevent recurrence, and total removal was impossible due to subdural invasion. He underwent radiation therapy and salvage chemotherapy. A third operation found only scar tissue. Maintenance salvage chemotherapy was continued. He was doing well 30 months after the first operation.

Giant pseudoaneurysm of the extracranial vertebral artery successfully treated using intraoperative balloon catheters

Traumatic pseudoaneurysms of the extracranial vertebral artery rarely occur, because of its deeply protected anatomical location. Because the direct surgical approach has resulted in high morbidity and mortality rates, ligation of the vertebral artery has been adopted, but this can cause an ischemia in the vertebrobasilar system. We report the case of a 73-year-old woman with a huge pseudoaneurysm of the right vertebral artery that occurred after attempted placement of a cardiac pacemaker. The aneurysm was 7 x 7 x 5 cm in size and its neck was situated just distal to the right subclavian artery. Direct surgical repair of the injured vessel and removal of the aneurysm were successfully performed using balloon catheters placed intraoperatively in both the innominate artery and the right vertebral artery.

[Clinical evaluation of lumbar disc hernia in the teenagers]

Lumbar disc herniation is a rare occurrence in teenagers. There are several questions as to its pathogenesis, relationship to trauma, and clinical manifestations compared with those in adults. In the present paper, we described nine cases of teen-age lumbar disc herniation, which accounts for about 3.3% of all the operated lumbar disc herniations in our clinic. In the discussion, 687 cases of teen-age lumbar disc herniation were analyzed from the world literature. The clinical signs and symptoms in teenagers showed no distinct difference from those in adults. Laségue's sign was found in nearly all the patients. Although direct or indirect trauma to the lumbar region may play an important role in causing disc herniation in teenagers, a more important factor seems to be the degeneration of the disc material, which begins in children earlier than usually suspected. Although surgical therapy has been advocated by many authors, it must be followed up for a long term before the efficacy of such treatment for teenagers can be confidently ascertained.

Capillary hemangioma in the cauda equina: neuroradiological findings

A case of capillary hemangioma of the cauda equina is reported. Myelography with water-soluble contrast material showed a complete obstruction of the contrast column at the L1-L2 level. Neither plain nor intravenously enhanced CT revealed the tumor. Spinal angiography showed a feeding vessel to the tumor and a faint tumor stain. Magnetic resonance imaging (MRI) showed a mass lesion of slightly higher than cauda equina intensity, which was clearly enhanced with Gd-DTPA. MRI, especially Gd-DTPA-enhanced study, plays the most important role in the diagnosis of a spinal capillary hemangioma. Spinal angiography was interesting in showing a tumour with a capillary blush.

Neuroradiological examination of thoracic radiculomyelopathy due to ossification of the ligamentum flavum

Sixteen cases of thoracic radiculomyelopathy due to ossification of the ligamentum flavum (OLF) were analyzed. The patients ranged in age from 39 to 78 years (average 57 years). There were 13 men and 3 women. A significant predilection of OLF for the lower thoracic spine (T9/10, T10/11, T11/12) was noticed. Plain X-ray of the thoracic spine and multidirectional tomography could give important information about the site of ossification. Computed tomography with the intrathecal injection of the water-soluble contrast material clearly demonstrated the ossification and the degree of compression of the spinal cord. The disadvantages of using computed tomography for diagnosing OLF included the necessity for the scan level to be previously decided by other methods because computed tomography of the entire spine was impractical. Magnetic resonance imaging was performed in 14 patients and gave important information about OLF and the compression of the spinal cord. The combination of MRI and computed tomography seems the most useful for the precise diagnosis of OLF.

[Surgical treatment of cervical spondylotic radiculomyelopathy with abnormal involuntary neck movements. Report of three cases]

Cervical spondylotic myelopathy usually arises in patients in their late 40s or early 50s, most frequently at the C5/6 and C6/7 levels. Recently, excellent results have been attained with microsurgery in cases of cervical spondylosis. On the other hand, treatment of cervical spondylotic myelopathy in patients with athetoid dystonic cerebral palsy entails several problems. The authors report three cases of such troublesome myelopathy. A 34-year-old male with severe athetoid movement showed cervical spondylotic myelopathy. Myelography and magnetic resonance (MR) imaging demonstrated compression of the spinal cord through the C3-C5 levels. A 47-year-old female with athetoid dystonic cerebral palsy presented myelopathy. Myelography and MR imaging showed instability and spinal cord compression at the C5/6 level. A 34-year-old male with spasmodic torticollis showed C6 radiculopathy due to cervical disc hernia at the C5/6 level. Cervical anterior decompression with interbody fusion brought temporary improvement in all the three patients. However, such problems as slippage of Halo-vest, difficulty in eating during Halo-vest fixation, relapse of neurological deficit, were experienced. Due to postoperative cervical instability, cervical laminectomy is considered to be contraindicated in such patients. Anterior decompression with bone fusion has been reported effective, but, if athetoid dystonia continues, there is a potential for myelopathic deterioration due to spondylotic changes adjacent to the fused vertebrae.

[Multiple spinal neurinomas without von Recklinghausen's disease: report of three cases]

Multiple spinal tumors are relatively rare and account for from only 1.2 to 9.5% of all spinal tumors. Half of the multiple spinal tumors are accompanied with von Recklinghausen's disease. Since March 1983, we have encountered 31 spinal tumors including 11 neurinomas, three of which were multiple and showed no manifestations of von Recklinghausen's disease. The incidence of multiple spinal tumors was 9.7% in our series. Altogether, 40 cases of multiple spinal neurinomas without von Recklinghausen's disease have been reported including our three cases. According to those 40 cases, much neurinomas occur 5 times more frequently in men than in women, and they are found predominantly in the lumbosacral region. In the present paper, we describe three cases of multiple spinal neurinomas, and compare the results of several neuroradiological examinations. Myelography was the most reliable method to determine whether or not the tumors were multiple. However, in cases where myelography was completely blocked out, other neuroradiological methods such as metrizamide-CT scan or MRI with Gd-DTPA intravenous injection were able to bring us information concerning multiplicity.

[Usefulness and limitations of neuroradiological examinations in lumbar canal stenosis]

Since 1983, we have performed 434 spinal surgery operations. Among them are included 51 cases of lumbar canal stenosis. For these 51 cases, we performed several neuroradiological examinations, such as lumbar plain X-ray, myelography, metrizamide-CT scan (Met-CT) and magnetic resonance imaging (MRI). We discussed and examined the usefulness and limitations of such neuroradiological methods for diagnosis of lumbar canal stenosis. On myelography, these 51 patients were divided into three types; a complete block type with 29 patients, soy-beans type with 7 patients and strangulation type with 15 patients. Myelography could show the level of stenosis, but could give little information about the compressing factors, particularly in complete-block type. Met CT was performed in 37 cases. In both strangulation type and soy-beans type which had been shown through myelography, Met-CT could clearly demonstrate the subarachnoid space, and several structures around the lumbar spinal canal could be clearly identified. In cases which myelography revealed as complete-block type, we identified two subtypes. In the first type subarachnoid space was clearly demonstrated by Met-CT. The second type was comprised of those cases where Met-CT scan could not demonstrate subarachnoid space at all. In the former group, useful information about lumbar canal stenosis could be obtained, but, in the latter, information was scarce. MRI was performed on 21 patients. MRI clearly showed the anatomical relationship of disc, subarachnoid space, yellow ligament and hypertrophied bony structure.(ABSTRACT TRUNCATED AT 250 WORDS)

[Carpal tunnel syndrome associated with long-term hemodialysis: case report]

Since Warren and Otieno reported carpal tunnel syndrome in patients on intermittent hemodialysis in 1975, a number of related reports have been published. However, there are few reports associated with neurosurgery about carpal tunnel syndrome in patients on long term hemodialysis. We reviewed this disease and reported our case. We treated a patient who complained of bilateral hand numbness and atrophy of the right thenar muscle. He had been suffering from chronic renal failure and had been treated with hemodialysis for ten years. We diagnosed carpal tunnel syndrome based on the findings concerning Tinel's sign, Phalen test, and the conduction velocity of the median nerve. We performed decompression surgery of the median nerve. However, although there was no recovery from thenar muscle atrophy, there was improvement of hand numbness. Histologically, amyloid deposits within the hypertrophic transverse carpal ligament on the right side, could be found but on the left side where the internal shunt had been made amyloid deposits were absent. The reason why patients receiving long term hemodialysis develop carpal tunnel syndrome is controversial, but it seems that beta 2 microglobulin may play an important role in developing carpal tunnel syndrome in hemodialysis patients. This was reported by Gejyo in 1985. There may be uremic and/or diabetic neuropathy in these patients, and these neuropathies may be responsible for the more rapid deterioration and poorer surgical results in carpal tunnel syndrome associated with hemodialysis than in idiopathic cases. It is most important that carpal tunnel syndrome has to be diagnosed early and that surgical decompression is performed while the disease is in its early stage.

[Influence of OK-432 on intratumor 5-fluorouracil concentration in cases given UFT]

The influence of OK-432 on the activation of UFT, consisting of tegafur and Uracil, was examined in patients with gastric cancer and colonic cancer. In 14 gastric cancer and 15 colonic cancer cases, to which UFT 400 mg/day and OK-432 2KE 2/W were administered orally and intra-muscularly for 2 weeks preoperatively until surgical treatment, intratumor 5-fluorouracil (5-FU) concentration was measured and compared with that of patients who given UFT 400 mg/day orally for 2 weeks (15 gastric cancer and 15 colonic cancer cases). As the results, in the groups of patients given OK-432, the concentration in gastric cancer tissue was 0.093 +/- 0.067 microgram/g and that in colonic cancer was 0.098 +/- 0.058 microgram/g. Both values exceeded 0.05 microgram/g which is considered to be the effective intratumor 5-FU concentration. No difference was observed in these cases given UFT alone. The ratio of intratumor 5-FU concentration vs. that of normal tissue was 2.5 for gastric cancer and 2.7 for colonic cancer and the ratio of tumor vs. serum 5-FU concentrations was 8.5 for gastric cancer and 10.9 for colonic cancer. No difference was also observed in these values in cases given UFT alone. From above results, it seemed that the clinical dose of OK-432 2KE 2/W had no influence on the activation of UFT, so that the combination therapy of UFT and OK-432 was found to be clinically useful.

[Experimental study of the usefulness of evoked potentials in predicting the reversibility of the brainstem function following infratentorial epidural balloon compression]

With few warnings signs, posterior fossa mass lesions can affect life-supporting brainstem systems directly and cause a precipitous failure of vital functions. Consequently, a technique, by which brainstem dysfunction could be detected at its reversible stage, would have clinical value. Recently manly reports have suggested that the evoked potentials might be advantageous in assessing a developing brainstem dysfunction and might be a more sensitive or reliable detector of deteriorating neurological function than the physical or neurological signs. To explore this possibility, we recorded somatosensory evoked potentials (SEP) and brainstem auditory evoked potentials (BAEP) serially during inflation and deflation of balloons placed in the suboccipital epidural space of cats, as a model of an acutely expanding posterior fossa lesion. The results were correlated simultaneously recorded cardiovascular and pupillary function and with supratentorial and infratentorial epidural pressure. In this study, N1 of cortical SEP (CSEP), wave IV of BAEP, and wave III of short latency SEP (SSEP) were found to be useful parameters in predicting the electrophysiological reversibility. Experimental results were as follows: 1) As the infratentorial epidural balloon was expanded, CSEP, wave IV of BAEP and wave III of SSEP showed remarkable changes both in latency and in amplitude. Decrease in blood pressure and pulse rate preceded or developed at the same time as the apparent change in CSEP. Futher expansion of the balloon resulted in Cushing phenomenon and lability of blood pressure.2) As long as wave IV of BAEP remained, and decompression was started within 15 minutes after N1 of CSEP were completely suppressed, changes in SEP. BAEP and cardiovascular function were all reversible.2+ decompression. (ABSTRACT TRUNCATED AT 250 WORDS)

[Transthoracic approaches to the lesions of thoracic cord and thoracic vertebrae]

Experiences of transthoracic approaches to the thoracic cord lesions were reported. Since 1983, we have performed six transthoracic approaches to the thoracic lesions; one thoracic OPLL, one dumbbell-shaped neurinoma, two thoracic soft disc, one epidural metastatic tumor to thoracic vertebrae. From the viewpoint of surgical anatomy, the thoracic vertebrae show a physiological kyphosis and the subarachnoid space of the ventral site is narrower than that of the dorsal site. Due to such anatomical characteristics, the thoracic laminectomy for decompression is not so effective as in the cervical or lumbar region and a relatively small mass lesion can bring a paraplegic state. The lesion of the ventral site of the thoracic cord has been regarded as no man's land because of poor results of posterior approaches. Instead of posterior approaches, anterior or anterolateral approaches with transthoracic route have been adopted. In the present paper, we used transthoracic anterolateral approaches for four patients and anterior sternum-splitting approach for two patients. The operative procedures of the approaches were described in detail. By these approaches, we could treat four patients with favourable results but the result of thoracic OPLL was poor. The cause of this poor result seemed to depend upon the intraoperative compression of the thoracic cord. For the troublesome complication, we described the postoperative cerebrospinal fluid leakage into thoracic cavity with respiratory disturbance. Several devices to prevent such troublesome complication were discussed.

Blue rubber bleb naevus syndrome

An autopsy case of blue rubber bleb naevus syndrome (BRB-NS) is reported. There was the usual occurrence of cavernous haemangioma in the skin and intestine and cardiac involvement by a haemangiomatous lesion might have directly led to the patient's death. By light and electron microscopy, all the haemangiomatous lesions examined were cavernous with the exception of the cardiac tumour which was a mixed-vessel (capillary and cavernous) type of a haemangioma. These findings indicate that any vascular tumour-like lesions may occur in BRBNS. The principal combination of haemangiomas in the skin and intestine in BRBNS regardless of their type is the typical feature of this syndrome.

[Experimental study of evoked potentials in predicting the reversibility of brain function following tentorial herniation]

Brainstem auditory evoked potentials (BAEP), somatosensory evoked potentials (SEP) and EEG were recorded sequentially in cat with mass-induced intracranial hypertension in correlation with mass volume, intracranial pressure (ICP), systemic blood pressure (BP) and size of the pupils. 1) As the intracranial pressure was raised by expansion of a supratentorial epidural balloon, suppression of cortical SEP (CSEP) and pupillary abnormality appeared first, EEG, waves IV and III of BAEP and wave III of short latency SEP (SSEP) were suppressed in this order. 2) As far as wave IV of BAEP remained and decompression was started within 30 minutes after peaks of CSEP completely suppressed, changes in P1 and N1 of CSEP were reversible. 3) Further raising of ICP was followed by loss of waves IV and III of BAEP and wave III of SSEP in this order. Simultaneously with loss of wave III in SSEP, systemic blood pressure dropped rapidly. By immediate balloon deflation after disappearance of wave III of SSEP, animals recovered from hypotension, but hardly from suppression in EEG, CSEP and BAEP. 4) Preservation of wave IV of BAEP indicated good improvement of pupillary abnormality even after removal of compression. These results suggest that for the patient with disturbed consciousness caused by supratentorial mass lesion, decompressive procedure should be started before wave V of BAEP and brainstem components of SEP disappear. EP monitor seems to be useful clinical method for preventing irreversible change of the brain in patients with coma caused by supratentorial mass lesions.

[Effects of pentobarbital anesthetic induction on sensory evoked potentials in the cat]

During the last decade, noninvasive electrophysiological tests with sensory evoked potentials have rapidly blossomed into useful clinical tools. They have been studied in large groups of normal subjects and in patients with a wide variety of neurologic diseases. Almost all experimental animal studies on sensory evoked potential, however, have not been undertaken under sufficient consideration on the effects of drugs used for induction into anesthesia on evoked potentials. In order to use evoked potentials as a tool for assessing neurological function in animals, it is necessary to known the effect of anesthetic agents on evoked potentials. Pentobarbital, Somnopentyl, is one of the drugs most commonly used for induction into anesthesia is animal experiments. Authors have attempted to study the long term effects of pentobarbital on evoked potentials. Intramuscular administration of anesthetic dose of pentobarbital was followed by prolongation of 11 and III waves of SEP and I-II interpeak latency of BAEP. Latency of N1 of SEP was also prolonged. On electroencephalogram, amplitude have increased and frequency have got slower after pentobarbital administration. These electrophysiological changes persisted over 5 hours after pentobarbital administration. These results suggest that in some studies on animals the residual effect of agents used for induction into anesthesia must be taken account for analysis of data obtained.

[Experimental study on the origins of far-field SEP to median nerve stimulation in the cat]

Results of various experimental and clinical studies on the origins of somatosensory evoked potentials (SEP) suggested that the far-field and early near-field potentials are generated primarily from sources within the dorsal column-medial lemniscal system. However, there are a few studies where direct depth recordings of SEP were performed and they were compared with surface-recorded SEP components. The purpose of this investigation is to determine the origins of somatosensory far-field and early near-field evoked potentials in cat by the analysis of distribution mode of surface-recorded SEPs, the comparison of depth recorded with surface-recorded SEPs and by the study of SEP changes caused by serial destruction of the structures relating to sensory pathway. A complex patterns of evoked potentials were recorded from cerebral epidural surface in cat by forelimb median nerve stimulation. The largest positive to negative slope was recorded from the epidural electrode on the sensory cortex contralateral to the stimulation. Five small positive potentials could be identified on the positive slope. We labeled these potentials as I, II, IIIA, IIIB, IV according to the report by Iragui-Madoz. The largest positive potential recorded from the VPL was coincident with the surface-recorded IIIB in latency at different interstimulus intervals. After transection of the midbrain-pons junction, IIIA remained unchanged, and the following waves disappeared. However, IIIA decreased in latency and markedly decreased in amplitude after transection of the pons at its rostral level. IIIA seems to be generated from the medial lemniscus at the level of osseous cerebellar tentorium.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effects of thiopental on sensory evoked potentials in the cat]

Noninvasive electrophysiological evaluation with sensory evoked potentials would be of clear diagnostic and prognostic value in evaluating comatose patients with stroke or severe head injury. In order to protect the brain from such kinds of insults, barbiturate coma therapy has been employed and its effectiveness has been already established. However, in the barbiturate coma therapy, it is occasionally difficult to distinguish the pharmacological effect of barbiturate from the preexisting brain dysfunction caused by the underlying process of the disease. In adult cats, authors studied changes of sensory evoked potentials following cumulative intravenous administration of thiopental which is used clinically for barbiturate coma therapy. P1 and N1 of cortical SEP showed tendency of gradual decrease in amplitude. However, no significant changes occurred in latency by stepwise increment of thiopental dose. Changes in amplitude of P1 and N1 of cortical SEP preceded to the flattening on electroencephalogram. Around at the level of the concentration where EEG changes began, I-II interpeak latency of BAEP and latency of wave I of short latency SEP started to increase. BAEP and early components of SEP (I.II.III.IV) persisted even in by far the higher level of serum concentration of thiopental than that of clinical use. Furthermore, most of these parameters showed no statistically significant change neither in amplitude nor in latency. These experimental results suggest that sensory evoked potentials will provide us with useful information in the assessment of the brainstem function in patients under thiopental induced deep coma.

[Implantable continuous epidural morphine infusion system for relief of chronic cancer pain]

Chronic cancer pain remains intractable by standard treatment in many patients and interferes with their mobility and independence. Epidural morphine infusion therapy is adopted for providing adequate analgesia in patients who are generally morphine independent and have intractable pain. A totally implantable pump system, Infusaid, has allowed continuous epidural morphine infusion without wound care or frequent percutaneous injections and with a potentially lowered risk of adverse reactions including respiratory suppression. Since December 1984, the authors have used this totally implantable drug delivery system for continuous epidural morphine infusion in two patients who had been suffering from chronic pain caused by pelvic cancer associated with metastatic and/or invasive lesions: Case 1: a 61-year-old man with rectum cancer; and Case 2: a 44-year-old man with colon cancer. Before system implantation, a therapeutic response to epidural morphine was confirmed by a one-shot test injection. Pain relief was evaluated by use of Visual Pain Analogue Scale Scores (VPASS). In spite of the presence of an artificial anus on the left abdomen in both patients and of pus discharge from a sacral infectious fistula on admission in Case 2, no infectious complication occurred in either case. Urinary retention developed after the implantation in Case 2, but this improved following the reduction of morphine concentration. No other adverse reaction was observed. In Case 1, the system was effective for 6 months until his death from advancing malignancy, and the patient was able to return to work three months after discharge.(ABSTRACT TRUNCATED AT 250 WORDS)

[Technical details for recording trigeminal evoked potentials in the cat]

Experiments were undertaken to establish technical standards for recording of trigeminal evoked potentials (TEP) as a tool for assessment of the effectiveness of various therapeutic procedures for trigeminal neuralgia. Serial changes in the action potentials of the maxillary nerve and TEP were studied when parameters of electrical stimulation, namely, intensity and frequency, and position of electrodes were altered. The effects of use of muscle relaxants and change of body temperature of animals on TEP were also studied. On the basis of these experimental results, the technical details most suitable for TEP recording in cat were explored. The most distinct TEP was recorded under the following animal conditions and parameters: keeping rectal temperature between 37.5 degrees C and 38.5 degrees C, slackening with muscle relaxants, stimulating the infraorbital nerve with 10 volts of square-pulse electricity 5 times per second in short latency TEP and 2 times per second in long latency TEP, placing the active electrode on the vertex for short latency TEP and on the primary sensory area for long latency TEP. Eight positive peaks and three negative peaks were recorded under these conditions. The average and standard deviations of peak latency of potential from 10 cats were as follows: P 1, 0.67 +/- 0.04 msec; N 1, 0.89 +/- 0.07 msec; P 2, 1.35 +/- 0.10 msec; P 3, 1.89 +/- 0.08 msec; P 4, 2.43 +/- 0.26 msec; P 5, 3.17 +/- 0.15 msec; P 6, 3.36 +/- 0.21 msec; P 7, 5.02 +/- 0.39 msec; P 8, 6.07 +/- 0.35 msec; N 2, 10.4 +/- 1.15 msec; N 3, 18.5 +/- 1.74 msec.(ABSTRACT TRUNCATED AT 250 WORDS)

[Technical problems in intraoperative monitoring of sensory evoked potentials]

Recent advances in both the equipment and the recording technique of sensory evoked potentials (EP) have brought high levels of versatility and reliability of objective measurement to the assessment of nervous system function. They have also allowed the use of intraoperative evoked potentials. The operating room, however, is usually considered a hostile environment, where various kinds of artifacts from surgical manipulation and generated by electrical armamentaria disturb electrophysiological recordings. Although several authors have reported on intraoperative EP monitoring, they have described few of the practical details of recording techniques. Having developed an intraoperative recording technique for evoked potentials over the past 3 years, we present the technical measures taken to overcome interference and obtain sufficiently stable and reliable EP recordings for intraoperative monitoring. All electrical equipment used in the operating rooms must, of course, be grounded securely. Even after grounding in the usual manner, however, artifacts appeared intermittently. The source was found to be a Mayfield-Kees three-pin head rest and a self-retaining retractor, both of which seemed to pick up electromagnetic radiation originating from electrocauteries and others. These artifacts could be minimized by grounding the head pins all each point of insertion into the patient's head and by use of a silicon-coated spatula rather than a metal one. In addition automatic artifact rejection by voltage overload sensing seems to be indispensable to eliminate the effect of extraneous mechanical and electrical interference which occur inevitably in surgical procedures.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effects of phenobarbital on EEG and sensory evoked potentials in normal cat brain]

In adult cats, authors studied changes in parameters obtained by the recordings of sensory evoked potentials following cumulative intravenous administration of phenobarbital. P1 and N1 of cortical SEP showed gradual tendencies to decrease in amplitude and to increase in latency with increasing barbiturate dose. These changes preceded to the appearance of burst-suppression activity on electroencephalogram. At this point I-II and III-IV interpeak latencies of BAEP showed statistically significant increase. BAEP and all early components of SEP (I.II.III) persisted in the extremely high serum concentration of phenobarbital. Furthermore, II-III interpeak latency of BAEP showed no statistically significant increase. These experimental results suggest that sensory evoked potentials will provide useful information in the assessment of the brainstem function in patients under deep coma.

[Effect of intravenous administration of diltiazem on cerebral blood flow and brain function]

The effect of intravenous administration of diltiazem on cerebral circulation and brain function were studied in animals. Diltiazem, at a dose of 150 micrograms/kg BW, was administered intravenously over a period of 5 minutes beginning 30 minutes after ligation of the right brachiocephalic artery in 9 cats in order to investigate its effects in the acute stage of cerebral ischemia. In 5 animals, mean arterial blood pressure was recorded and blood flow in the basilar artery was measured transdurally by use of an ultrasonic Doppler flow-meter. Mean arterial blood pressure began to elevate immediately after ligation of the right brachiocephalic artery, but the degree of elevation was minimal. It began to fall during diltiazem injection and returned to the preadministration value 30 minutes after injection. Basilar artery flow decreased slightly during injection of diltiazem, but began to increase after completion of injection. The increase relative to the preadministration value was 62 +/- 31% 10 minutes after injection, 88 +/- 38% 20 minutes after, and 24 +/- 53% 30 minutes after. The short latency somatosensory evoked potentials (short latency SEP) recorded in the other 2 animals showed no noticeable change either in amplitude or latency during the same procedures. In 1 of 2 animals in which brainstem auditory evoked potentials (BAEP) were monitored, the latency of peak IV increased after ligation of the right brachiocephalic artery, and decreased 20 minutes after injection of diltiazem.(ABSTRACT TRUNCATED AT 250 WORDS)

[Experimental study on the effect of ultrasonic surgical aspiration on blood flow and nerve function by use of ultrasonic Doppler flowmeter and auditory brainstem evoked response]

The effect of intracranial use of an ultrasonic surgical aspirator on major cerebral vessels and nervous tissue was studied in anesthetised adult cats. Experiments were performed without suction in order to investigate only the effect of ultrasonic emulsification. The flow rate of irrigation saline over the tip of the ultrasonic aspirator was set at either slow (4 ml/min) or fast (24 ml/min). Flow in the common carotid artery and superior sagittal sinus was studied by ultrasonic Doppler flowmetry during direct or indirect (intermediated by muscle fragment) application to the vessels of ultrasonic vibration for periods of 5 min. each in increments of 20% from 20% of maximal intensity. Flow in both the carotid artery and the superior sagittal sinus changed only with direct application on vascular surface of ultrasonic vibration of at least 80% of maximal intensity; otherwise flow in these vessels was not changed. The temperature rise caused by ultrasonic vibration was studied by use of a thermister buried in the brain parenchyma of animals 2 mm from the ultrasonic vibratory probe tip. A rise above the physiological range could be prevented by sufficient irrigation. The effect of ultrasonic vibration on the brainstem was studied by using auditory brainstem evoked response (ABR) to monitor brainstem function. An ultrasonic vibratory probe was applied to the ventral surface of the brainstem exposed by transclival approach. ABR changed noticeably only when ultrasonic vibration of 60% or more of maximal intensity was applied directly; otherwise ABR was not changed. The effect of ultrasonic vibration on the intracranial acoustic nerve was also studied by ABR.(ABSTRACT TRUNCATED AT 250 WORDS)