Cerebral sparganosis in a child

Cerebral sparganosis in childhood is very rare. Until 1996, 2 cases in children up to 15 years of age had been described. We report a case of cerebral sparganosis in a 6-year-old girl who presented with seizures. Sequential brain magnetic resonance imaging scans spaced over 4 months showed a lesion which migrated from the right parieto-occipital region to the right occipital region. The enzyme-linked immunosorbent assay for antisparganum antibody was positive. She most likely contracted sparganosis from worm-infested spring-water. A live worm with surrounding granulomatous tissue was removed, and the enzyme-linked immunosorbent assay for antisparganum antibody converted to negative 12 months following surgery. In areas of endemic sparganosis, the possibility of cerebral sparganosis should be considered, even in a child, if the patient shows a migrating granulomatous lesion.

Cerebral sparganosis: clinical manifestations, treatment, and outcome

Cerebral sparganosis is a rare parasitic disease caused by infestation by the plerocercoid larva of Spirometra mansoni. The authors retrospectively analyzed 17 cases of cerebral sparganosis treated at Seoul National University Hospital between 1986 and 1994. The patients' ages at diagnosis ranged from 6 to 57 years (median 32 years) and the male/female ratio was 13:4. Diagnosis was based on radiological findings, serological test results, operative findings, and histopathological examinations. Characteristic magnetic resonance (MR) findings consisted of widespread white matter degeneration and cortical atrophy, mixed-signal lesion (low in the central and high in the peripheral regions on T2-weighted images) with irregular dense enhancement of central foci and changes in the location and shape of the enhancing lesion in follow-up studies. Ten patients underwent surgical removal of the parasitic lesion, six received medical treatment alone (five with praziquantel and one with antiepileptic drugs), and one underwent insertion of a ventriculoperitoneal shunt and a course of praziquantel. Follow-up periods ranged from 13 to 111 months (mean 49 months). Seven patients who underwent complete removal of the lesion, live worm, or degenerative worm with surrounding granuloma showed a favorable course. Patients who received medical treatment alone or incomplete removal exhibited progression in their neurological deficits and their seizures could not be controlled. Medication with praziquantel seemed to have no killing effect on live worms. The authors conclude that MR imaging is the most valuable modality for the early detection of cerebral sparganosis and that complete surgical removal of granuloma together with worms, whether they are alive or degenerative, is the treatment of choice.

Experimentally induced Chiari-like malformation with myeloschisis in chick embryos

Though several pathogenetic theories concerning the frequent association of Chiari malformation and hydrocephalus with myeloschisis have been suggested, none of them explains all the aspects of the disorder. To investigate whether myeloschisis is the direct cause of Chiari malformation and hydrocephalus or these conditions are the results of another basic event, we observed the morphological changes of the posterior cranial fossa and its components in the chick embryos with surgically induced myeloschisis. To make myeloschistic lesions, we opened the neural tube for a length of 9-11 somites in Hamburger and Hamilton stage 16-19 chick embryos. They were divided into cervicothoracic (C-T) and lumbosacral(L-S) groups according to the area of incision. The embryos were re-incubated until postoperative day 11. In the control group, embryos were incubated with the eggshell window open as their experimental counterparts. The survival rates of each group were as follows; 11% (9 survivors/85 operated embryos), 8% (7/83), and 17% (10/60) in the C-T, L-S and control groups, respectively. Myeloschisis positive rates were 100% in the operated groups and 0% in the control group. The heads of embryos were sectioned along the sagittal plane to observe the morphological changes in the posterior cranial fossa and its components. Of the survivors, five in the C-T group, two in the L-S group and six in the control group were available for light microscopic inspection. In the majority of embryos with myeloschisis, without difference between the C-T and L-S groups, the fourth ventricles were smaller than those of the control group and the subarachnoid spaces in the posterior cranial fossa were also narrower. In embryos with severe changes, the cerebellum displaced downward comparing with that of the control embryos. No evidence of hydrocephalus was present Though not always typical, morphological changes similar to Chiari malformation were observed in chick embryos with surgically induced myeloschisis. It suggests a strong direct causal relationship between the two conditions and supports the theories of derangements in cerebrospinal fluid dynamics rather than those of primary mesenchymal or neural origin as a pathogenetic mechanism of Chiari malformation.

Concanavalin-A-induced open neural tube defects in chick embryos

Open neural tube defects developed in 12 of 122 alive chick embryos treated with exogenous lectin (concanavalin-A) at stages between 10 or 14 as defined by Hamburger and Hamilton. Embryos treated at stage 10, the time of anterior neuropore closure, developed exencephaly or extensive neural openings from the level of rhombencephalon to the thoracic spinal cord, while embryos treated at stages between 11 and 14, at posterior neuropore closure, developed only small myeloschisis in the thoracolumbar region. The failure of neural tube closure at a critical time is a major cause of neural tube defects.

Primary intramedullary spinal cord primitive neuroectodermal tumor with intracranial seeding in an infant

Primary spinal cord primitive neuroectodermal tumor (PNET) is a rare entity. In all 13 cases have been reported in the literature, including 3 with intracranial seeding. A 3-month-old girl with involvement of the spinal cord below the mid-thoracic level is described. The brain MRI revealed findings indicative of seeding along the intracranial subarachnoid space. Biopsy, duraplasty and removal of laminotomy flap were done. In spite of a good response to the first cycle of postoperative "8-drugs-in-a-day' chemotherapy, further treatment was refused. She died 21 days after the onset of leg weakness, which reveals the rapid progression of untreated cases. To our knowledge, this is the first case of spinal cord PNET with parenchymal involvement that has been described in an infant.

Promotion of synthetic amyloid beta-peptide fibrillization by cell culture media and cessation of fibrillization by serum

Dulbecco's modified Eagle's medium promotes aggregation and fibrillization of the synthetic amyloid beta 1-40 and beta 1-42 peptides more than RPMI and OPTI media. Fibrillization in all of these media is faster than in phosphate-buffered saline and Tris buffer. Normal and heat-inactivated fetal bovine and human serum abolish amyloid fibril formation in buffers and cell culture media. Fibrillar amyloid formed during 2-day-long incubation in cell culture media and buffers is defibrillized by 1-day-long treatment with human and bovine serum. This study indicates that amyloid beta fibrillogenesis in cell culture should be studied in serum-free media or in media with a low concentration of serum.

Terminal myelocystocele--a case report

Terminal myelocystocele is a rare form of occult spinal dysraphism in which the hydromyelic caudal spinal cord and the subarachnoid space are hemiated through a posterior spina bifida. A 1.5 month old boy presented with a large lumbosacral mass and urinary incontinence. The magnetic resonance imaging, operative findings and pathological findings revealed a low lying conus with a dilated central canal dorsally attached to the subcutaneous tissue. Ventral subarachnoid space was enlarged and herniated through the laminar defect of the sacrum. The lesion was typical of a terminal myelocystocele. The clinical features are different from those of myelomeningocele in many aspects. Though the incidence is low, terminal myelocystocele should be included in the differential diagnosis of congenital lesions presenting as a lumbosacral mass.

Intractable seizures associated with brain tumor in childhood: lesionectomy and seizure outcome

The authors retrospectively reviewed ten pediatric brain tumor patients with intractable seizures who underwent lesionectomy without intentional identification and resection of the epileptogenic region to assess the clinical features and seizure outcome after lesionectomy in such patients. Seizures were complex partial in seven cases and simple partial, absence, and generalized tonic-clonic in one case each. Tumors were located at the medial temporal lobe in four cases, at the frontal lobe in four cases, at the parietooccipital and the suprasellar areas in one case each. The most common pathology was benign oligodendroglioma (five cases) followed by ganglioglioma (two cases). Others were pleomorphic xanthoastrocytoma, hamartoma, and primitive neuroectodermal tumor (one case each). In four cases, complete removal of the tumor was feasible. Postoperatively nine of the ten patients showed favorable seizure control (Engel's classification 1 and 2) and of these, six were seizure-free during the follow-up period (mean duration: 40 months). Therefore, lesionectomy can be an appropriate initial treatment for patients with brain tumor and medically intractable seizures.

Functioning periods and complications of 246 cerebrospinal fluid shunting procedures in 208 children

To investigate the functioning periods and the causes of cerebrospinal fluid shunt failures, 246 shunts inserted in 208 children from October 1985 to August 1992 at the authors' institute were retrospectively reviewed. The mean age at shunt insertion was 4.0 years and the reasons for the shunting procedures were congenital hydrocephalus (47.6% per procedure), tumor-associated hydrocephalus (21.1%), postmeningitic hydrocephalus (11.8%), congenital cyst (10.6%) and others (8.9%). All except 2 were shunted to the peritoneal cavity. Forty-five operations for shunt failure were done (18.3%) during the follow-up period (mean, 32 months). The functioning (shunt survival) rates at 6, 12, 24 and 36 months after surgery were 91.6%, 86.6%, 83.6% and 82.9%, respectively. The complications were mechanical malfunction (12.2%), infection (4.1%), subdural fluid collection which required drainage (1.6%) and migration (0.4%). About half of the mechanical malfunctions and infections which had occurred during the follow-up period were within 6 months and 2 months after surgery, respectively. There was no shunt-related mortality. These chronological data should be considered in the planning of follow-up schedules.

Proximal migration and subcutaneous coiling of a peritoneal catheter: report of two cases

The authors report two cases with a rare complication of ventriculoperitoneal shunt. The peritoneal catheters migrated upward to the scalp and to the clavicular area. In one case, the whole length of the peritoneal catheter was pulled out from the peritoneal cavity and was coiled subcutaneously. Both of the patients had the habit of head rotation and one of the patients had a history of subcutaneous fluid collection at the site of coiling. At surgery, whitish inflammatory granulation tissues were noted around the catheter in both cases, which might act as an anchoring point for the "windlass effect".

Infarction of the territory supplied by the contralateral superior cerebellar artery in a case of descending transtentorial herniation

Infarction of the territory supplied by the contralateral superior cerebellar artery in cases of descending transtentorial herniation has not been reported. The authors experienced a primitive neuroectodermal tumor in a patient whose consciousness deteriorated transiently due to descending transtentorial herniation. On the magnetic resonance imaging taken 8 days after the herniation, lesions thought to be infarction of territories supplied by the ipsilateral posterior cerebral artery and the contralateral superior cerebellar artery were noted. The possible mechanism of this peculiar pattern of infarction is discussed.

Morphological study of surgically induced open neural tube defect in old (14 and 21 days) chick embryos

As an experimental model for the research of open neural tube defect (NTD), the surgical model has several advantages over others, in spite of the fact that the pathogenetic mechanism is not compatible with the human intrauterine events. To make reproducible NTDs by surgery and to compare the surgically induced lesions with the human myeloschisis morphologically, we opened the neural tube for a length of 9-11 somites in Hamburger and Hamilton stage 16-19 chick embryos. Embryos which survived until the late in ovo life (total age 14 and 21 days) showed relatively reproducible open NTDs. Morphologically they are similar to human myeloschisis. This study suggests that the surgical model can be suitable for studies of open NTDs.

Successful treatment of hereditary progressive dystonia--a case report

Hereditary progressive dystonia or Segawa disease is a very rare disease. Diagnosis depends on typical clinical features with remarkably good response to levodopa and normal laboratory findings. Here, we report on a unique case of Segawa disease with a fixed equinovarus foot. The patient was a twenty one year old female with the typical clinical manifestations since eight years of age who became wheel-chair dependent at the age of fifteen. The dystonia responded well to levodopa except for the foot deformities. The foot deformities were successfully corrected by use of the Ilizarov apparatus and she ambulated freely at follow up. Since several similar foot deformities appeared in the early stage of a progressive neurological degenerative disease, the treatable Segawa disease should be added to the differential diagnosis when facing a patient with pes equinovarus.

Irreducible volar rotatory dislocation of the proximal interphalangeal joint

Volar rotatory dislocation of the proximal interphalangeal (PIP) joint often cannot be reduced by closed manipulation because of interposition of soft tissues. In this case, the condyle of the proximal phalanx was trapped between the central slip and the lateral band. This case is reported to reemphasize the importance of recognizing serious injuries involving the soft tissues around the PIP joint. Deprival of its normal dorsal stabilizing forces can cause a loss of both static and dynamic joint support. Secondary scarring and contractures affect all damaged structures of the joint.

Intercondylar fractures of the distal humerus: routine anterior subcutaneous transposition of the ulnar nerve in a posterior operative approach

Intercondylar fractures of the distal humerus in adults are rare and notoriously difficult to treat. The goals of open reduction are to preserve the articular surface and restore elbow function. We treated 20 patients by open reduction with dual-plate internal fixation and routine anterior subcutaneous transposition of the ulnar nerve. The follow-up period ranged from 15 to 35 months. The fractures were classified according to Muller's system. The results were evaluated using the Cassebaum rating system and subjective functional status. Excellent or good results were achieved in 15 elbows (75%), two had a fair result, and three, poor. A clearer understanding of fracture patterns, rigid dual-plate internal fixation, and early rehabilitation are needed to improve the results from this vexing injury. We recommended routine ulnar nerve anterior subcutaneous transposition using a posterior approach. Compared with published reports, our preliminary results demonstrated no postoperative ulnar nerve compression syndrome at follow-up. Routine anterior subcutaneous transposition of the ulnar nerve to avoid the postoperative ulnar nerve compression syndrome is required.

Traumatic patellar tendon ruptures: a follow-up study of primary repair and a neutralization wire

Thirty-five patients with traumatic patellar tendon ruptures treated with primary repair and with a neutralization wire were retrospectively reviewed. All the ruptures occurred in acute trauma; 12 of the patients (34%) had multiple injuries, and 19 had open wounds around the knee joints. The diagnostic clues included a high-riding patella by palpation or seen on roentgenograms, hemarthrosis, a palpable gap over the tendon, and inability of patients to extend the knee actively. Using the criteria of Siwek and Rao, at follow-up 57% of outcomes were rated as excellent; 28.6% as good; and 14.2% as unsatisfactory. None of the 35 patients had a rerupture of the tendon. We conclude that primary repair with a neutralization wire can be a treatment of choice for traumatic patellar tendon ruptures.

Diastematomyelia--clinical manifestation and treatment outcome

Diastematomyelia is a rare congenital anomaly characterized by a division of the spinal cord or the filum terminale into two parts. In Korea, only one case has been reported. The authors have operated on 5 cases of diastematomyelia with septum since July, 1978. The ages ranged from 1 to 44 years (median; 11 years). There were 2 boys, 2 girls and an adult man. The disease manifested by cutaneous abnormalities and neurological or orthopedic deficits. Pain was a chief complaint in the adult patient. The symptoms had progressed in 3 cases. The diagnosis was made correctly by CT myelography or MRI in 4 cases. The median septum was located at the lumbar area in 4 cases and at the lumbosacral region in 1 case. Associated abnormalities included low lying conus (5 cases), lipoma (2 cases), thickened filum terminale (1 case), hemilipomyelomeningocele (1 case) and syrinx (1 case). The median septum was removed. The dural sleeve adjoining the septum was resected and the dural sac was reconstructed. The role of MRI in the diagnosis and planning of surgery and the high frequency of associated low lying conus were emphasized. Though the surgical treatment relieved pain, it did not reverse the neurological deficits or orthopedic deformities significantly, which suggests the beneficial effects of early surgical intervention in the cases with progressive symptoms.

Morphological study of surgically induced open neural tube defects in chick embryos--postoperative 24 hours

For the experimental study of neural tube defect (NTD), a surgical model has advantages over other models in a few aspects. It causes less functional derangement of cells and the NTDs can be made selectively by surgery. The authors planned to use the surgical model for the experimental study of NTD. As the first step for the studies, the chronological changes of morphology during the early postoperative period were investigated using postincubation 3-day chick embryos. The objectives of this study are (1) the morphological evaluation of the surgical model as a method for studies of open NTD, and (2) the observation of morphological changes for the first 24 hours after surgery which include 'overgrowth' appearance and the continuity between the surface ectoderm and the neuroectoderm. The morphological changes were observed by light microscope and scanning electron microscope. Immediately after surgery, typical open NTDs were observed. Morphologically they were very similar to the appearance of spontaneous (non-surgical) open NTDs. The opened neural tubes were everted progressively and they looked rather flat at 24 hours after surgery. Cellular hyperplasia ('overgrowth' appearance) was noted within 24 hours after surgery and became more prominent during the 24 hours. There was increasing continuity between the surface ectoderm and the neural tissue until 24 hours after surgery when the continuity looked almost complete. In conclusion, surgically induced NTDs are morphologically very similar to spontaneous NTDs.(ABSTRACT TRUNCATED AT 250 WORDS)

Coracoid process fracture combined with acromioclavicular dislocation and coracoclavicular ligament rupture. A case report and review of the literature

A coracoid process fracture associated with acromioclavicular joint dislocation and with rupturing of the coracoclavicular ligaments of an adult has been reported only once in the literature. This report adds another unusual case to the literature to reemphasize the importance of recognizing this unusual lesion. Two separate mechanisms--direct trauma to the shoulder girdle and sudden pull on the coracoid process by the conjoined tendons of short head biceps and coracobrachialis muscles--appear to be responsible for this unusual triple lesion. Open reduction with coracoid screw and acromioclavicular fixation, combined with an All-dredge repair to replace the ruptured coracoclavicular ligaments, resulted in an excellent outcome.

Traumatic patellar tendon ruptures--a follow-up study of primary repair and neutralization wire

Thirty-five patients with traumatic patellar tendon ruptures treated with primary repair and neutralization wire were retrospectively reviewed. The length of follow up ranged from 1.5 years to 5 years with an average follow up period of 20 months. All the ruptures occurred due to acute trauma, twelve of them (34%) involved in a multiple injuries, and nineteen had an open wounds around the knee joints. The diagnostic clues included a high riding patella by palpation or by X-ray, hemoarthrosis, a palpable gap over the tendon; and being unable to extend the knee actively. Using the criteria of Siwek and Rao, at follow up 57% were rated as excellent, 28.6% good; and 14.2% unsatisfactory. None of the 35 patients had a rerupture of tendon. It is recommended that primary repair with a neutralization wire can be a treatment of choice for traumatic patellar tendon ruptures.

Treatment outcome and prognostic factors of medulloblastoma

Medulloblastoma, once a tumor with a dismal prognosis, is one of the most common primary brain tumors of childhood. As the methods of treatment have been continuously refined, the outcome has improved remarkably during the last few decades. The outcome of 78 medulloblastoma patients, which were managed from 1972 to 1992 at the Department of Neurosurgery of Seoul National University Hospital, were analyzed to calculate the 3-year and 5-year survival rates (3yS and 5yS). Of those, 52 cases which were treated after July 1982 were studied 1) to calculate the 3yS and 5yS, 2) to figure out the prognostic factors of survival, and 3) to investigate the role of adjuvant chemotherapy ('8-drugs-in-a-day' protocol: CCNU, cisplatin, vincristine, hydroxyurea, procarbazine, cytosine arabinoside, methylprednisolone and cyclophosphamide). The 3yS and 5yS of the 78 patients were 57.4% and 47.3%, respectively. Of the 52 patients treated after July 1982, the 3yS and 5yS were 67.8% and 64.1%, respectively. The latest recurrence was at 56 months after surgery. All the recurrences were within the risk period of Collins' rule. Of the prognostic factors studied by univariate analysis (age, sex, Chang's classification T- and M-stages, extent of surgical removal, and chemotherapy), Chang's classification M-stage and sex were the statistically significant factors (p = 0.028 and 0.024 respectively). On multivariate analysis, only the M-stage was statistically significant (p = 0.004). Adjuvant chemotherapy had different influences in different patient groups. Only in the 'poor risk' group, did adjuvant chemotherapy have a strong tendency to better outcome (p = 0.069). Further data collection and analysis will lead to better treatment modalities and better outcome for this most common primary malignant brain tumor in childhood.

Synthesis of steroid intermediates via alkylation of dianion derived from acetoacetic ester

A synthetic route for A-ring aromatic steroid intermediates starting from alkylation of dianion derived from acetoacetic ester with m-methoxyphenylethyl bromide to form benzene ring connected to a linear six-carbon fragment is described. This unit, after chemical modifications to 5, was condensed with 2-methylcyclopentan-1,3-dione (6a) to form prochiral trione, 7a, a key synthetic intermediate in A-ring aromatic steroid. Microbial reduction of 7a with Schizosaccharomyces pombe (NRRL Y-164) gave chiral (-)-11 in 65% yield. Starting from 2,2-dimethylsuccinic acid, 2,4,4-trimethylcyclopentan-1,3-dione (6a) was prepared, which was condensed subsequently with 5 to form racemic 7b trione intermediate. Asymmetric cyclization of 7b in the presence of L-(-)-phenylanlanine, followed by acidic cyclization led to regiospecific synthesis of 16,16-dimethyl tetracyclic steroid intermediate.

Histopathological changes of the cat brain in experimental sparganosis

Histopathological changes of the brain were observed in 22 mongrel cats each of which was subjected to intracranial inoculation of 3 or 5 plerocercoids of Spirometra erinacei. The brains were examined at 2 weeks, 1, 3, and 6 months post-inoculation (PI). Grossly, the brain lesion consisted of a mass of worm capsule and/or hemorrhagic tract. Microscopically hypertrophied astrocytes, lymphocytes, plasma cells, RBCs, polymorphonuclear leukocytes, and hemosiderin laden macrophages were found around the worms or tracts in all groups. The number of reactive astrocytes increased mainly in the white matter. In the lesions 3 months PI, the sectioned worms were encircled with fibrous tissue along with numerous RBCs, inflammatory cells, and necrotic debris. Collagenous fibers were also demonstrated. Outside the inflammation, a wide edematous zone developed and numerous neuroglial fibers were also found. The location of the worms or the tracts was random in the brain lobes, but the worm seemed to migrate mainly along the white matter.

[Midazolam and Meperidine for colonoscopy]

We studied the sedative, analgesic and amnesic effects of intravenous midazolam and meperidine for colonoscopy, and also compared patient's satisfaction, changes of vital signs, safety and complications with intramuscular meperidine during the colonoscopy. Two hundred and ninety-nine patients undergoing physical check-up were randomized to receive intramuscular meperidine 50 mg and Hyoscine-N-Butylbromide (buscopan) 20 mg (Group IM-MB, n = 57) or intravenous midazolam 0.05 mg/kg, meperidine 1 mg/kg and buscopan 20 mg (Group IV-MMB, n = 242) before colonoscopy. All patients were closely observed and arterial oxygen saturations (SaO2) were monitored with pulse oximeter in Group IV-MMB. The demographic data of both groups were similar. There were significantly more severe pain responses (grimacing, moaning, shouting for pain, abdominal rigidity and body moving during colonoscopy) in Group IM-MB (51%) than in Group IV-MMB (13%) (p < 0.01). In immediate procedure recall after recovery from medications, 39% of Group IM-MB remembered severe pain during colonoscopy and only 3% of Group IV-MMB did (p < 0.01). 92% of Group IV-MMB who felt satisfactory with the medications were significantly higher than 21% in Group IM-MB (p < 0.01). Both groups significantly increased in heart rate after the injection of medications (p < 0.01). Group IM-MB increased 15 +/- 18% and Group IV-MMB 61 +/- 28% with significant difference between groups (p < 0.01). This might be caused by meperidine, buscopan, and relative hypovolemia of patients. There were significant decreases in SaO2 in Group IV-MMB, mean 4.5 +/- 1.7% (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Spinal congenital dermal sinus--experience of 5 cases over a period of 10 years

Spinal congenital dermal sinus (CDS) is a rare entity which supposedly results from the failure of the neuroectoderm to separate from the cutaneous ectoderm during the process of neurulation. The lesions are most frequent at the lumbosacral followed by the occipital region. CDS of the thoracic region is very rare. The patients with spinal CDS present with meningitis and/or mass effect from the associated inclusion tumor. They are usually dermoid or epidermoid cysts. Teratoma is rarely associated. The authors experienced 5 cases of spinal CDS over a 10 year period. Of the 5 cases, 2 were at thoracic and 3 were at lumbosacral levels. Dermoid cyst, epidermoid cyst and teratoma were associated in one case each. Two cases presented with neurological deficit and meningitis while an additional case presented with neurological deficit and a history of probable meningitis. Pain was present in 2 cases. Magnetic resonance imaging played an important role in the diagnosis of the lesion and planning of surgery. All the cases showed a good response to surgery even though one patient had persistent neurological deficit.

Simultaneous dislocation of the five carpometacarpal joints with concomitant fractures of the tuberosity of the trapezium and the hook of the hamate: case report

Multiple carpometacarpal dislocations, with fractures of the trapezium and hook of the hamate carpals are rare. We report an exceedingly rare constellation of these injuries. The routine use of a carpal tunnel view is advised to identify the associated avulsion fractures with multiple carpometacarpal dislocations. We found little on this subject in existing papers. It is important because painful nonunion of avulsion fractures and compressive ulnar or median neuropathy may be ignored and thus not receive suitable treatment.

Intracranial mesenchymal chondrosarcoma: a case report and literature review

Intracranial mesenchymal chondrosarcoma is a rare entity. The case of a 13-year-old girl with mesenchymal chondrosarcoma which seemed to arise from the dura mater is presented here together with a review of the literature. In the present case, the tumor involved the superior sagittal sinus. It recurred 21 months after gross total removal of the mass and coagulation of the involved wall of the superior sagittal sinus. Reoperation was performed followed by radiation therapy.

Preenhanced computed tomographic findings in brain death

A patient complying with the clinical criteria for brain death was studied by preenhanced computed tomography (CT). Preenhanced CT showed apparent increased density at the base of the brain along the course of the major arterial vessels, and abnormally dense-appearing deep venous structures, like those of contrast-enhanced CT. There was a diffuse decrease in brain density with a poorly delineated ventricular system. These CT findings were very characteristic. CT as a non-invasive method seems to be valuable in the diagnosis of brain death. The relevant literature is reviewed and mechanisms showing those CT findings are discussed.

The use of a DNA-binding domain replacement method for the detection of a potential TR3 orphan receptor response element in the mouse mammary tumor virus long terminal repeat

TR3 orphan receptor is a human homologue of the mouse nur77, N10 and rat NGFI-B, TIS1 genes which may represent an early response gene involved in the control of cell proliferation. We have studied potential target genes for TR3 orphan receptor using the DNA-binding domain replacement method. We found that mouse mammary tumor virus long terminal repeat-linked chloramphenicol acetyltransferase expression can be activated in transfected cells by a chimeric androgen receptor/TR3 orphan receptor/androgen receptor construct (AR/TR3/AR) in the presence of androgen. By deletion analysis, a region with 20 nucleotides in length between positions -1178 and -1159 of the mouse mammary tumor virus long terminal repeat was confirmed as a potential TR3 orphan receptor response element. These results suggest that feasibility of using the DNA-binding domain replacement method to detect target sequences of orphan receptors.

Oligodendroglioma in childhood

Fifteen pediatric (age under 16) cases of oligodendroglioma (ODG) were surgically proven from January 1985 to April 1992 at the Division of Pediatric Neurosurgery, Seoul National University Children's Hospital. To observe the proportion of ODG's in primary intracranial tumors, the location of ODG's and the prognostic significance of the histological grading of ODG's in childhood, the 15 cases of pediatric ODG's were retrospectively analyzed. ODG's accounted for 5.6% of pediatric primary intracranial tumors operated on during the same period. Nine tumors were located in the cerebral hemisphere (3 cases each in the frontal, temporal and parietooccipital lobes), 1 in the thalamus, 2 in the pons-medulla, 2 in the cerebellum and 1 in the thoracolumbar spinal cord. Four tumors were anaplastic and an additional case showed positive cerebrospinal fluid (CSF) cytology for tumor cells. All the cases of anaplasia or positive CSF cytology had a poor outcome. All the seven cases of benign ODG's in cerebral hemispheres presented with seizures which were controlled with or without medication after tumor removal.

Spinal cord ganglioglioma in childhood

Two childhood cases of spinal cord ganglioglioma are described. Both cases showed a remarkable similarity in presentation, radiologically and morphologically. The first case was a 6 1/2-year-old boy who had ganglioglioma involving the entire length of the spinal cord. He has been suffering from a long span of scoliosis and gait disturbance since he was 1 year. The tumor contained multiple syrinx. The second case was a 3-year-old girl with ganglioglioma involving a large portion of the spinal cord from lower medulla to T3. This case also contained syringobulbia and syringomyelia in the multiple levels. She suffered from progressive motor weakness of all extremities. Owing to a good demarcation from normal spinal cord, the tumors could easily be removed by the microsurgical dissection through second stage operation in both cases. Histopathologically and ultrastructurally, the tumors were benign gangliogliomas. The symptoms improved a lot after surgery. Based on our two cases and literature review we confirmed that the spinal cord gangliogliomas are slowly growing tumors occurring in childhood or young adulthood. They often involve usually extensive level or entire length of the spinal cord and may be accompanied by scoliosis and gait disturbance when the tumor presents since infancy or early childhood as in our cases. They also often exhibit a cystic change of the tumor associated with large or small syringomyelia. Nearly total removal is possible due to a good demarcation from the normal spinal cord. Therefore, early diagnosis and surgical management are fundamental for the avoidance of unnecessary delay of surgery and a good result.

Brachial plexus injury with erect dislocation of the shoulder

Luxatio erecta, or inferior dislocation of the glenohumeral joint, is an extremely uncommon variety of shoulder dislocation. Several types of neurovascular injuries may be associated with luxatio erecta. Concomitant fracture of the coracoid, clavicle, acromion, greater tuberosity, and humeral head may also be noted. A case of luxatio erecta associated with a fracture of the greater tuberosity and transient mixed brachial plexus injuries is presented.

Ultrastructure of the microglia that phagocytose amyloid and the microglia that produce beta-amyloid fibrils

The function of microglia associated with beta-amyloid deposits still remains a controversial issue. On the basis of recent ultrastructural data, microglia were postulated to be cells that form amyloid fibrils, not phagocytes that remove amyloid deposits. In this electron microscopic study, we examined the ability of microglia to ingest and digest exogenous amyloid fibrils in vitro. We demonstrate that amyloid fibrils are ingested by cultured microglial cells and collected and stored in phagosomes. The ingested, nondegraded amyloid remains within phagosomes for up to 20 days, suggesting a very limited effectiveness of microglia in degrading beta-amyloid fibrils. On the other hand, we showed that in microglial cells of classical plaques in brain cortex of patients with Alzheimer's disease, amyloid fibrils appear first in altered endoplasmic reticulum and deep infoldings of cell membranes. These differences in intracellular distribution of amyloid fibrils in microglial cells support our observations that microglial cells associated with amyloid plaques are engaged in production of amyloid, but not in phagocytosis.

Ultrastructural studies of the cells forming amyloid in the cortical vessel wall in Alzheimer's disease

Ultrastructural studies of serial sections of the vessels with amyloid deposits in the brain cortex of patients with Alzheimer's disease showed that cells in the position of pericytes--perivascular cells--and perivascular microglial cells are producers of amyloid fibrils in the vascular wall. Three types of changes from normal are distinguishable in the vessel wall: (1) semicircular or circular thickening of vascular wall containing a large amount of amorphous material and various number of amyloid fibrils, (2) tuberous amyloid deposits containing both amorphous material and amyloid fibrils, some of the fibrils being arranged in strata and others arranged radially, and (3) amyloid star composed of a predominantly radial arrangement of bundles of amyloid fibrils and a less prominent amorphous component. A mixture of amorphous material and amyloid fibrils is present in cell membrane invaginations of perivascular cells, and occasionally perivascular microglial cells. Bundles of amyloid fibrils are found in altered cisternae of the endoplasmic reticulum and in the channels confluent with the infoldings of the plasma membrane of perivascular microglial cells. The amyloid deposition in the wall of the vessel causes degeneration of endothelial cells and the reduction of, and in some vessels obliteration of, the vessel lumen. In areas affected by amyloid angiopathy, extensive degeneration both of the neuropil and of neurons was observed. These changes were accompanied by astrogliosis. This study demonstrates similarities in amyloid formation in amyloid angiopathy and in beta-amyloid plaques in the neuropil and suggests that cells of the mononuclear phagocyte system of the brain (perivascular cells and perivascular microglia) are engaged in amyloid fibril formation.

Computed tomographic finding in adenomyomatosis of the gallbladder

We report on an uncommon case of symptomatic generalized adenomyomatosis of the gallbladder. It was initially suspected by ultrasonography and further confirmed by computed tomography (CT). A postcontrast CT scan at the level of the gallbladder body demonstrated the characteristic rosary sign. The rosary sign is formed by the enhanced proliferative mucosal epithelium with the intramural diverticula surrounded by the unenhanced hypertrophied muscle coat of the gallbladder. Similar CT scans were obtained sequentially in the caudal direction. These CT scan findings indicated generalized adenomyomatosis of the gallbladder. The patient received a cholecystectomy. The pathologic report showed specific changes of adenomyomatosis corresponding to the findings on the CT scan. Generalized adenomyomatosis of the gallbladder, therefore, can be accurately diagnosed by CT.

Necrotizing fasciitis of the extremities

Necrotizing fasciitis is a limb- and life-threatening soft-tissue infection. Eighteen patients with necrotizing fasciitis of the extremities were reviewed. These infections occurred most commonly after minor trauma. Associated chronic debilitating diseases were present in 13 patients. All but two infections were polymicrobial. The overall mortality rate was 33%. Death was caused by persistent wound sepsis in three and systemic septic complications in spite of apparent local infection control in three. At the admission physical examination the condition may resemble a benign, low-grade cellulitis. Three of four patients died because of a delay in surgical debridement for more than 24 hours after admission. Multiple radial debridements of the involved skin, fat, and fascia are essential to control progressive necrosis. Our results suggest that early diagnosis and prompt surgical debridement of necrotizing fasciitis are essential for survival.