Hearing preservation in acoustic neuroma surgery by the extended middle cranial fossa method

The results of attempted hearing preservation were investigated in 160 cases of acoustic neuroma surgery carried out by a team of otologists and neurosurgeons at Keio University Hospital during a 14-year period from 1976 to 1989. Surgery was carried out by the middle cranial fossa (MCF) approach in the earlier cases and by the extended middle cranial fossa (EMCF) approach in the more recent cases. Measurable postoperative hearing was preserved in 20 of the 160 cases. Preoperatively, 22 cases had tumors of 20 mm or smaller in diameter, hearing levels (HL) of 50 dB or lower, and speech discrimination scores (SDS) of 50% or higher; 8 (36%) met these conditions postoperatively. Among those cases with hearing preserved postoperatively, hearing was unchanged from the preoperative level in 9 cases and changed in 11 cases. Total tumor removal was achieved in 19 cases. In one case, part of the tumor was left in order to preserve hearing, but MRI and CT have revealed no change in hearing or tumor enlargement to date, at 4 1/2 years after surgery. Hearing was preserved but progressively deteriorated postoperatively in one case in which the tumor was believed to have been totally removed but there was recurrence and in another case of total resection of neurofibromatosis II. Postoperatively, there were increased incidences of absence of the stapedius reflex, Type V by Békésy audiometry, and prolongation of the IT5, disappearance of Wave V, and no response in measurements of the ABR.

Classification of the extended middle cranial fossa approach

There are several possible operative approaches to acoustic neuroma surgery. Ideally, there should be no need to select among approaches according to tumor size or indications for hearing preservation. The ideal approach should also allow otologists and neurosurgeons to work as a team using the same operative field and achieve functional preservation (facial nerve function and hearing) in a high percentage of cases. In 1977, the authors first reported on the extended middle cranial fossa (EMCF) approach for AN surgery. Based on our 15-year experiences of this approach, we have classified it into 3 types and describe their indications and techniques in the present paper. In addition, we examine the advantages and disadvantages and emphasize its excellent applicability as a team approach for otologists and neurosurgeons.

Results of acoustic neuroma surgery by the extended middle cranial fossa approach

The results of surgery in 160 cases of AN are reported. Surgery was carried out by the extended middle cranial fossa (EMCF) approach in 138 cases and by the middle cranial fossa (MCF) approach in 22 cases. The tumor extended an average of 28.9 mm into the posterior cranial fossa; 42% of the tumors extended 31 mm or more. Mortality was 1.9%. Of the 3 cases of death, two had large tumors of 45 mm and 52 mm each, and one was a case of recurrence. Total tumor removal was achieved in an average of 78.8% of the cases. When the cases were classified by date of operation, the total tumor removal rate in the 60 most recent cases was 93.3%. The rate of facial nerve presentation was 82.4% on average and 93% in the recent cases. Hypoglossal-facial nerve anastomosis was performed in 33% of the cases in which facial nerve function failed to recover for an extended period of time. Among recent cases, however, anastomosis has been carried out in 22% of the cases. Hearing was preserved in 20 cases. Useful hearing was preserved in 8 (38%) of 22 cases. Recurrence was confirmed through surgery in 3 cases. Recurrence was suspected but was unconfirmed in 3 cases.

Ceruminoma with intracranial invasion--case report

Ceruminous gland tumors (ceruminomas), which usually involve the external auditory canal, are rare. A case of ceruminoma invading the temporal bone and histologically proven to be papillary adenoma is presented. The tumor recurred and invaded intracranially after subtotal removal and was finally diagnosed as adenocarcinoma. The importance of early diagnosis and radical treatment is stressed.

Mixed pituitary adenoma and gangliocytoma associated with acromegaly--case report

A gangliocytoma in the sellar region is very rare. We report a case of an intrasellar gangliocytoma complicated by pituitary adenoma presenting with acromegaly. A 52-year-old female was admitted to our hospital with headache, mild acromegaly, and bitemporal hemianopsia, and endocrinological study found a high serum level of growth hormone (GH). A computed tomographic scan revealed a tumor in the sellar region, which was almost totally removed by trans-sphenoidal surgery. Histological examination of the resected specimen showed diffuse, chromophobe-type pituitary adenoma, partially containing cholesterin clefts. Areas of clusters of dysmorphic neurons, adjacent to or mixed with pituitary adenoma, were diagnosed as gangliocytoma. The immunohistochemical examination showed GH-releasing hormone (GRH)-positive dysmorphic neurons and GH-positive pituitary adenoma. We consider that the trophic effect of GRH secreted by the neurons of GRH-producing intrasellar gangliocytoma probably caused the GH-producing pituitary adenoma.

Tetrahydrobiopterin-dependent production of L-dopa in NRK fibroblasts transfected with tyrosine hydroxylase cDNA: future use for intracerebral grafting

In the present study, tyrosine hydroxylase (TH; EC 1.14.16.2) cDNA was transfected into cultured fibroblasts and the production of L-3,4-dihydroxyphenylalanine (L-DOPA) was determined. Type 2 TH cDNA was transfected into fibroblasts (NRK-49F) derived from the normal rat kidney, and the expression of the TH minigene was screened by immunocytochemical staining and immunoblotting analysis with TH antiserum. Several clones of the NRK transfectants that produce TH molecules were obtained. The expressed TH molecules showed high enzyme activity in a complete assay system in vitro. However, L-DOPA was not detected in the cultured cells due to the possible absence of de novo synthesis of (6R)-L-erythro-tetrahydrobiopterin (BH4) in these cells. When BH4 was added to the medium, a large amount of L-DOPA was detected not only in the cells but also in the medium. These findings may aid in regulating the amount of L-DOPA secretion from cells after they are transplanted into the brain.

Xenogeneic neural transplantation: role of vasculature and MHC antigen in immunological rejection

The reconstruction of blood vessels in a graft is one of the important events inducing immunological rejection. First, we investigated the reconstruction of blood vessels in a graft by using a monoclonal antibody against mouse endothelial surface antigen 1. Secondly, the lymphocyte proliferative response to Ia antigen were examined in mixed lymphocyte cultures by using monoclonal antibodies against Ia antigen. The results show that the blood vessels originating in the host tissue inoculate with those originating in the donor graft tissue and that the expression of Ia antigen on the vascular endothelial cells plays an important role in the immunological rejection through sensitization of peripheral lymphocytes.

Mosaic reconstruction of blood vessels in mouse neocortical tissue transplanted into the third ventricle of rat brain

Newborn mouse neocortical tissue was transplanted into the third ventricle of rat brain and the reconstruction and the origin of the blood vessels were investigated by using a monoclonal antibody against mouse endothelial surface antigen-1 (MESA-1). It was clearly demonstrated that some of the blood vessels in the graft originated in the donor mouse neocortical tissue. An India ink perfusion experiment revealed that the blood was supplied to the MESA-1-positive blood vessels. Furthermore, electron microscopic immunohistochemical studies demonstrated the existence of a mosaic reconstruction of blood vessels which consisted of mouse- and rat-derived vascular endothelial cells. It was concluded that the blood vessels originating in the donor tissue and those originating in the host tissue inoculate with each other in the grafted tissue.

Synthesis of L-3,4-dihydroxyphenylalanine by tyrosine hydroxylase cDNA-transfected C6 cells: application for intracerebral grafting

In the present study, we obtained genetically manipulated nonneuronal cells which synthesize a catecholamine precursor for future use in intracerebral grafting. Human type 1 tyrosine hydroxylase (TH; EC 1.14.16.2) cDNA was inserted into eukaryotic expression vector pKCRH2 and was co-transfected into C6 cells with plasmid pSV2neo. Expression of the TH minigene was screened by immunohistochemical staining with TH antibody and immunoblotting analysis. Several clones of the C6 transfectants that produce TH molecules were obtained. These cells showed TH activity, and the product, L-3,4-dihydroxyphenylalanine (L-DOPA), was detected intracellularly due to the absence of L-amino acid decarboxylase (EC 4.1.1.28) activity. It was found that a large amount of L-DOPA was released from the cells into the culture medium. These transfectants were transplanted into rat brain, and the expression of TH was examined immunohistochemically. On the 10th day following transplantation, a mass of C6 cells which was heavily stained with TH antibody was observed in the brain. These findings may provide us with an opportunity to investigate the effects of intracerebral transplantation of nonneuronal cells that produce catecholamine or its precursor.

Nonfamilial turcot syndrome presenting with astrocytoma--case report

A nonfamilial case of Turcot syndrome (glioma-polyposis syndrome) is described. A 16-year-old male with no siblings first developed a frontal astrocytoma, and was later found to have colonic polyposis with adenocarcinoma. The family history was negative for the syndrome, but his parents were first cousins.

Hearing preservation in acoustic neuroma surgery and postoperative audiological findings

One hundred fifty-three cases of acoustic neuroma were treated surgically by the middle cranial fossa approach or extended middle cranial fossa approach. Attempts to preserve hearing were made in 30 cases with tumours extending 2.0 cm or less into the posterior fossa; successful hearing preservation was achieved in 12 cases. Among the 15 patients with preoperative hearing levels (HL) of 50 dB or lower and speech discrimination scores (SDS) of 50% or higher, hearing was preserved in 9 (60%) patients. A similar rate of hearing preservation was achieved among the patients with normal or near-normal hearing. Compared with those patients in whom hearing could not be preserved, those with hearing preservation had better HL, higher SDS, and less abnormal ABR findings preoperatively. Postoperatively, the HL and SDS deteriorated slightly. In addition, there was a marked prolongation of the IT5, and the incidence of absence of the stapedius reflex increased. Compared with the preoperative HL, the postoperative HL was unchanged in 5 cases; deteriorated temporarily and then improved in 5 cases; and deteriorated, though with hearing preserved, in 2 cases. Intraoperative monitoring was conducted by recording the ABR and VIII nerve compound action potentials and by electrocochleography. However, postoperative hearing could not always be predicted from the findings obtained at the end of the operation.

Expression of Ia antigen on vascular endothelial cells in mouse cerebral tissue grafted into the third ventricle of rat brain

The mechanisms of the immunological rejection after xenogeneic neural transplantation were investigated with special reference to the expression of class II major histocompatibility complex (MHC) antigen (Ia antigen) on the grafted tissue. Tissue from a newborn mouse cerebral cortex was transplanted into the third ventricle of a 4-week-old rat brain. Infiltration of cytotoxic T-cells into the grafted tissue was investigated immunohistochemically by using a monoclonal antibody (OX-8). The infiltration began 8 days after transplantation and continued until about 4 weeks when the tissue was completely rejected. The expression of Ia antigen was also investigated immunohistochemically. The Ia antigen was first detected in the grafted tissue at 6 days after transplantation. The Ia antigen was considered to be expressed on the vascular endothelial cells judging from the staining patterns and the location of India ink which was perfused from the host's left cardiac ventricle. The perfusion experiments with India ink also revealed that blood was supplied to the grafted tissue from 5 days after transplantation. These results suggest that the expression of Ia antigen on the vascular endothelial cells renders the grafted tissues competent to initiate and participate in the immune reaction. The results also raise a possibility that the expression of Ia antigen is triggered by blood supplied from the host brain. In addition, the results indicate that the Ia-positive blood vessels do not originate in the host brain but are intrinsic to the grafted tissue.

[Cystic pineocytoma successfully treated with synchronized chemoradiotherapy. Case report]

A case of pineocytoma associated with intraventricular and meningeal metastasis is reported. The patient, a 25-year-old female, was admitted complaining of headache. Computed tomography revealed an irregular-shaped pineal lesion enhanced by contrast medium and accompanied by a cyst. An intraventricular cystic metastatic lesion and meningeal metastasis were also suggested. Biopsy of the pineal region proved the lesion to be a pineocytoma without neuronal or glial differentiation. Ventriculoperitoneal shunting was performed, and radiation therapy combined with chemotherapy (ACNU and vincristine) was administered. This treatment apparently destroyed both the primary and metastatic lesions, and the patient returned to her normal life. In 4 years of follow-up there has been no recurrence of the tumor. Pineocytoma with meningeal metastasis usually has a poor prognosis, but in this case combined radiation therapy and chemotherapy was curative. Although pineocytoma is rarely accompanied by a cyst, in cases of a pineal lesion coexistent with a cyst, a diagnosis of pineocytoma should be considered.

[Xenon-enhanced CT CBF measurements in intracranial vascular malformations]

In the management of intracranial vascular malformations, it is important to know the regional cerebral blood flow in its surrounding structure. However, CT scan with contrast medium and angiography have only a limited ability to estimate the rCBF. In this study, stable xenon-computerized tomography scanning by means of the end-tidal gas-sampling method was performed in eleven patients with intracranial vascular malformations. Seven of the patients had arteriovenous malformations, three had venous angiomas and one had aneurysm of the vein of Galen. In two patients with large arteriovenous malformations, in two with "larger" venous angioma and in one with aneurysm of the vein of Galen, rCBF values were significantly reduced, particularly adjacent to the malformations. In contrast, there were no areas showing reduced rCBF in cases where the malformations were small. This indicates development of ischemia correlates with the size of malformations. From the xenon-enhanced CT scan and angiographic findings, the presence of steal phenomenon with venous congestion might be a cause of rCBF reduction in those cases where ischemia exists.

Radical surgery of a galenic aneurysm with regional cerebral blood flow analysis. A case report

Successful surgical treatment of a case of aneurysm of the vein of Galen is presented. An 11-month-old boy was admitted with episodes of convulsive attacks. Neuroradiological examination revealed an aneurysm of the vein of Galen filled by branches of posterior cerebral arteries and left thalamoperforating artery. Regional cerebral blood flow, which was measured by a method of xenon-enhanced computed tomography, showed a low flow area in the frontal and occipital regions. The aneurysm was approached through the bilateral parietooccipital interhemisphere, freed from the feeders, and ligated. During the operation, cortical blood flow was monitored for prevention of normal perfusion pressure breakthrough. After the feeders were successfully clipped, the blood flow increased and became normalized in the related cortex. There was no postoperative neurological deterioration.

Reorganization of cerebellar cell suspension transplanted into the weaver mutant cerebellum and immunohistochemical detection of synaptic formation

Dissociated cells prepared from the cerebellar primordia of normal 15-day mouse embryos were grafted into the cerebellum of 1-month-old weaver mutant mice which are characterized by degeneration of cerebellar granule cells during the early postnatal period. The growth of the grafted cells was investigated at 1 month after the operation. Implanted cells were highly developed to form a large mass of tissue in the host cerebellar folia. Histological examination revealed that a trilaminar cortical structure was partially developed in certain areas of the grafted tissue. The implanted granule-like cells were labeled with [3H]thymidine which was injected into the host, suggesting that the granule-like cells actively proliferate in the host cerebellum after the transplantation. In this area, strong immunoreactivity with synapsin I was detected indicating that the dissociated granule cells of the cerebellar primordia are able to develop a synaptic organization in the weaver mouse cerebellum.

[A case of alpha coma in acute brainstem dysfunction--consecutive electroencephalograms and evoked potentials]

A 31-year-old woman was admitted because of severe headache and dysarthria in December 1985. Neurological examination on admission revealed severe impairment of consciousness, anisocoria, absent light reflex on the right side, and evidence of left hemiparesis, but other brainstem reflexes were intact. A CT scan taken shortly after arrival demonstrated a large hematoma in the right temporal lobe and the right cerebellum. Breathing became irregular and intubation was needed. An emergency operation was performed. After the operation the patient remained comatose without any spontaneous respiration or brainstem reflexes. The next day she was still comatose without any spontaneous movement and other neurological finding remained unchanged. An initial EEG obtained at this time showed an 8- to 9-Hz alpha rhythm of about 15-40 microV with preponderance over the posterior and central regions. Some spontaneous variability was noted. The same day, investigations of brainstem auditory evoked potential (BAEP), visual evoked potential (VEP), and somatosensory evoked potential (SEP) were performed. BAEP showed only the first, second and third waves (I-III) bilaterally. VEP was able to elicit the primary response (II-III) without the secondary response. SEP could not be obtained from the early cortical response to left median nerve stimulation, but showed N14 bilaterally and small N20 upon right median nerve stimulation. On the second day of hospitalization, a repeated EEG showed generalized slowing with loss of alpha frequency rhythms and it proved impossible for SEP to elicit N20 bilaterally. At this time, BAEP showed bilateral I-IIIth waves and VEP still showed primary response.(ABSTRACT TRUNCATED AT 250 WORDS)

A simple technique to measure regional cerebral blood flow during intravascular balloon clamping

A case of giant internal carotid ophthalmic aneurysm was presented. In order to clarify whether the patient could tolerate carotid occlusion, a balloon clamping test was performed. before surgery. The cerebral blood flow was measured using early imaging by single photon emission computed tomography (SPECT) with N-isopropyl-(iodine-123)-p-iodoamphetamine (123I-IMP). When the balloon clamping test was performed the tracer was injected, and scanning was performed 35 minutes after removing the catheter. This tracer enabled a "memory of blood flow" during temporary ischemia to determine the character of quick diffusion and slow wash out, that could not be performed by other methods of cerebral blood flow measurement. SPECT with 123I-IMP can simplify the measurement of cerebral blood flow during the balloon clamping test.

[Intraoperative electrophysiological monitoring for hearing preservation in acoustic neurinoma surgery]

Five acoustic neurinomas have been operated with hearing preservation as a goal. We monitored intraoperative brainstem auditory evoked potentials (BAEP) in all five cases, electrocochleogram (ECoG) using needle electrode in external auditory meatus in four, and compound action potentials directly recorded from the cochlear nerve (CAP VIII) in three. In all five cases the tumor was totally resected and cochlear nerve was anatomically preserved. However, in only one case useful hearing was preserved with preservation of all wave forms of the BAEP. Another patient with preservation of all wave forms of BAEP and the ECoG showed postoperative severe hearing loss. Other three patients showed postoperative severe hearing loss: only Wave I of BAEP and ECoG were preserved without preservation of the CAP VIII in one whose cochlear nerve was thought to be damaged in cerebellopontine angle cistern; Wave I of BAEP, ECoG and CAP VIII were preserved in one in whom it was suggested cochlear nerve near brainstem or cochlear nucleus was damaged; none of the BAEP, ECoG and CAP VIII was preserved in one in whom it was suggested distal cochlear nerve, or internal auditory artery was damaged. These different patterns of changes suggested that different causes for the hearing loss and difficulties in hearing preservation during acoustic neurinoma surgery. Having identified the putative mechanism of the hearing loss by monitoring those potentials, suggestions are made about how such hearing loss might be avoided. For preservation of the hearing in acoustic neurinoma surgery, all of those potentials including all wave forms of BAEP, ECoG and CAP VIII should be preserved during surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

[Folliculo-stellate cells in normal human adenohypophyses and in pituitary adenomas]

Nine normal human adenohypophyses and 155 cases of pituitary adenoma of various endocrinological types were studied for existence of folliculo-stellate cells (FSCs) by an immunohistochemical method using the antibody for S-100 (S-100 protein). In all normal materials, S-100 positive FSCs were distributed throughout the glands, constituting 0.9-4.0% of the adenohypophysial cells. FSCs were morphologically characteristic showing a few slender cytoplasmic processes which extended among the other endocrine cells. On the other hand, FSCs were recognized in 13 cases (8%) of the adenomas, which we called FSC-containing pituitary adenomas. In them, S-100 positive FSCs existed diffusely in the tissue and increased in number, but did not differ in appearance from those in the normal gland. We also examined immunoreactivity of FSCs for the anti-GFAP (glial fibrillary acidic protein) antibody. GFAP positive cells showed a greater number than S-100 positive cells in the normal glands, but a smaller number in the adenomas. Ultrastructural features of FSCs were observed in the tumor by an electron microscope. We studied clinical aspects of these FSC-containing adenomas, expecting some common features. However, we found no rules in age, sex, endocrinological type, tumor size, previous therapy, intraoperative finding of the tumor, and recurrence. So far, the function of FSC has not been clearly elucidated, and the present study did not contribute in this respect. The property of FSCs which proliferate in some adenomas is enigmatic. They may be entrapped normal cells, or reactive hyperplastic cells, or neoplastic cells. We considered them reactive hyperplastic cells.(ABSTRACT TRUNCATED AT 250 WORDS)

[Clinicophysiological study of multimodality evoked potentials and computed tomographic findings in persistent vegetative state]

The auditory brainstem response (ABR), short latency somatosensory evoked potential (SSEP) and visual evoked potential (VEP) of patients in the persistent vegetative state (PVS) are reported, and the correlations between the electrophysiological findings and the CT scan findings with the three clinical grades of the PVS (transitional, incomplete and complete vegetative syndromes) are discussed. Twenty two patients in a vegetative state caused by subarachnoid hemorrhage (3), hypertensive intracerebral hemorrhage (5), cerebral infarction (6), head injury (3), cerebral anoxia (4) and brain tumor (1). Each evoked response was evaluated for the presence or absence of abnormalities and assigned a grade ranked I to III. Briefly an evoked response was assigned a grade I, II, III if it satisfied the respective criteria of normal, moderately abnormal and severely abnormal or absent electrical activity. On the other hand CT scan findings in the PVS were evaluated for abnormal low density areas, ventricular dilatation and enlargement of the sulci and cisterns indicative of atrophy of the brain parenchyma. SSEP and VEP were better correlated with the clinical grade than ABR, and upper brainstem atrophy and abnormal low density area in CT scan findings were more valuable as an index to expresses the clinical features than ventricular dilatation. On the basis of these results, it is concluded that studies of ABR, SSEP and VEP associated with CT scan findings in the PVS could be a useful diagnostic aid to evaluate the lesions of these patients.

A modified extended middle cranial fossa approach for acoustic nerve tumors. Results of 125 operations

During the past 10 years, 125 operations for acoustic nerve tumors were performed on 114 patients at the authors' institution using a modified extended middle cranial fossa approach. This approach is based on a combination of King and Morrison's translabyrinthine-transtentorial approach and on the extended approach through the middle cranial fossa described by Bochenek and Kukwa. There were two hospital deaths (operative mortality 1.6%). In 102 operations on the initial tumor, total removal was performed in 89 cases (87%), and in 71 (80%) of these the facial nerve was anatomically preserved. Intracranial end-to-end anastomosis was performed on five of the 18 sacrificed facial nerves; a facial-hypoglossal anastomosis was carried out in the remaining 13 patients and in five (7%) of the 71 patients whose anatomically preserved facial nerve functioned poorly. In seven (39%) of the 18 patients in whom an attempt to preserve hearing was made, postoperative hearing was saved. In 23 operations on 17 patients for recurrent tumors, most of which had previously been removed subtotally via the suboccipital approach, total removal was accomplished in 13 (57% of the 23 reoperations and 76% of the 17 patients). At reoperation, the facial nerve was preserved in six (55%) of the 11 patients in whom the facial nerve had not been sacrificed. Postoperative leakage of cerebrospinal fluid occurred in 11 cases (8.8%), with rhinorrhea in 10 cases and otorrhea in one. Five of the fistulas were corrected by surgery and the rest healed spontaneously. Other complications were not significant.

Immunohistochemical studies on the proliferation of reactive astrocytes and the expression of cytoskeletal proteins following brain injury in rats

The appearance of reactive astrocytes following brain injury was investigated in 4-week-old rats with special reference to their proliferation and chronological changes in the cytoskeletal proteins. Two days after the injury, glial fibrillary acidic protein (GFAP)-positive cells had increased in number around the lesion and spread to the entire ipsilateral cortex by 3 days after the injury. To investigate the distribution of mitotic cells and its chronological change, immunohistochemical staining with monoclonal antibody to bromodeoxyuridine (BrdU) was performed. BrdU-positive cells began to appear around the lesion and spread to the entire ipsilateral cortex by 3 days and their distribution was the same as that of GFAP-positive cells. To investigate the association of GFAP-positive cells with cell division, double labeling experiments using [3H]thymidine autoradiography and immunohistochemical staining with antiserum to GFAP were performed. Cells doubly labeled with GFAP and [3H]thymidine were localized in the area adjacent to the lesion, in the molecular layer of the cortex and in the white matter. By contrast, none of the cells were doubly labeled in the IInd to VIth layers of the cortex. Furthermore, only astrocytes in the former areas expressed vimentin transiently from 2 to 10 days after the injury. In the rats administered vincristine, cells arrested during mitosis were found in the regions which express vimentin. From these results, it was suggested that astrocytes in the molecular layer of the cortex and the white matter adjacent to the lesion proliferated in response to the injury and expressed vimentin transiently, then acquired GFAP, and that astrocytes in the IInd to VIth layers of the cortex became reactive astrocytes without mitosis.

Immunohistochemical studies on synapse formation by embryonic cerebellar tissue transplanted into the cerebellum of the weaver mutant mouse

Normal cerebellar tissue, obtained from 15-day-old CBA/JNCij mouse embryos, was transplanted into the cerebellum of 4-week-old weaver mice. At the 6th week after the transplantation, the grafted tissue was distinguishable from the host cerebellum, developing a trilaminar organization. The formation of synapses by the implanted granule cells was analyzed immunohistochemically with antiserum against synaptic vesicle protein, Synapsin I. Some areas in the host cerebellum as well as in the grafted tissue were intensely stained by anti-Synapsin I serum, suggesting that the implanted granule cells make synaptic contacts with the neuronal cells.

[Basal skull metastasis of stomach cancer presenting with Garcin's syndrome--a case report]

A case of 57-year-old man with Garcin's syndrome is reported. By means of upper gastrointestinal endoscopy, this patient proved to have a stomach cancer. He noticed left trigeminal neuralgia for the first time in early Jan. 1986, and when he was referred to our department, his symptoms and signs of left cranial nerve palsy (from 5th to 12th, totally 8 nerves) were complete, although other neurological findings such as long tract signs, cerebellar signs, or papilledema were all negative. Although skull X-ray and basal skull tomography revealed neither bony deformity nor destruction, CT scan and angiography showed suspicious appearance of basal skull invasion of a certain mass. CSF examination revealed no malignant cells or abnormal protein, and sugar content. Exploratory craniotomy for tumor biopsy was performed. Histologically, the tumor had characteristics of anaplastic carcinoma. General survey revealed that he had a stomach cancer which was histologically the same as the basal skull tumor. His general condition became so serious that irradiation to the lesion was not indicated Among many papers reported about Garcin's syndrome, those of basal skull metastasis of stomach cancer are extremely rare. The authors discussed the lesion in comparison with meningeal carcinomatosis involving cranial nerves.

[Monitoring of antidromic facial nerve action potentials in cerebello-pontine angle tumor operations]

A method of recording the antidromic facial nerve compound potential (AFNAP) is presented. When the facial nerve is stimulated, a compound action potential is propagated in both directions from the stimulating site. We recorded AFNAP's in 6 cases of cerebello-pontine angle (CP angle) tumors (5 acoustic neuromas and one epidermoid) using a bipolar silver ball-type electrode directly put on the facial nerve in CP angle by stimulation of the peripheral facial nerve at the stylomastoid foramen. It was necessary to use needle electrodes instead of surface ones for stimulation to keep the artefacts from stimulating currents within reasonable bounds. Good contact of the electrode tips with facial nerve was required to get clear action potential. By stimulation with needle electrodes AFNAP's were recorded without averaging and had a good reproducibility. AFNAP's were typical triphasic potentials and the major negative peak latencies were observed from 1.5 to 3.4 msec except one case of recurrent epidermoid whose major negative peak latency was 7.6 msec. It was verified that these potentials were the results of facial activity, because they were recorded exclusively on the facial nerve, they could not be recorded at the proximal end of the sectioned facial nerve, and alterations of latency were observed with changing the position of recording electrode along the facial nerve. A calculated conduction velocity was about 50 m/sec. It was thought that recording AFNAP facilitated the identification of the facial nerve on the surface of the CP angle tumor, because the amplitude of AFNAP decreased immediately when the recording electrodes were off from the facial nerve.(ABSTRACT TRUNCATED AT 250 WORDS)

Subcultured astrocytes suppress the proliferation of neuroblasts in vitro

The effects of subcultured astrocytes on the proliferation of neuronal precursor cells (neuroblasts) from rat embryonic cerebral hemispheres were examined. The survivability of neurons and the neurite outgrowth were significantly enhanced by the subcultured astrocytes compared to those of neurons plated on poly-L-lysine-coated coverslips. The incorporation of [3H]thymidine into neuroblasts was remarkably suppressed by the subcultured astrocytes indicating that the astrocytes inhibit the proliferation of neuroblasts. These results suggest that astrocytes enhance the maturation of neuroblasts possibly via either cell-cell contact or trophic substances.

Possible association of platelet-derived growth factor (PDGF) with the appearance of reactive astrocytes following brain injury in situ

The association of platelet-derived growth factor (PDGF) with the appearance of reactive astrocytes following injury was investigated by using a specific antagonist of PDGF, Trapidil. The cerebral cortex of 4-week-old male rats was unilaterally injured with a 22-gauge needle. Immunohistochemical staining with antiserum to glial fibrillary acidic protein revealed that reactive astrocytes had increased in number around the wound by 2 days following the injury and had spread to the ipsilateral areas distant from the wound by 3 days. The appearance of reactive astrocytes in areas distant from the wound was dramatically suppressed by the administration of Trapidil. This finding indicates that PDGF might play a role in gliosis following injury.

The effect of arcuate nucleus transplantation on the development of the anterior pituitary in monosodium glutamate-treated rats

Treatment with monosodium glutamate (MSG) during the neonatal period is known to produce a selective lesion of the arcuate nucleus in rat brain, which is the major site of production of growth hormone releasing-hormone (GRH), followed by a secondary reduction in growth hormone (GH) synthesis in the anterior pituitary. Normal arcuate nuclei from hypothalamic areas of newborn rats were transplanted into the third ventricles of 27-day-old rats which were treated with MSG on alternate days for the first 10 days of life. Ninety days after birth, the anterior pituitaries were examined for GH synthesis by immunohistochemical staining with GH antiserum. The results indicated that the impaired GH synthesis in the anterior pituitary treated with MSG was partially restored in some recipients by grafts of arcuate nuclei in which the GRH-containing neurons were clearly detected by immunohistochemical staining with GRH antiserum.

Septal deafferentation enhances the neurotrophic effects of rat hippocampus on cultured neural cells from the central nervous system

Neurotrophic effects (NTEs) of various brain regions of 4-week-old rats were examined in primary culture of rat embryonic cerebral hemispheres. Extracts of the hippocampus, brainstem and septal nucleus highly enhanced the survivability of neuronal cells and the division of non-neuronal cells by 9 days. The septohippocampal tract (fimbria fornix) was cut and the effect on the neurotrophic activity in the hippocampus was examined. The NTEs of hippocampal extracts remained unchanged 3 days after septal deafferentation, was significantly increased by 7 days, peaked at 14 days and returned to the basal level by 21 days.

Transplantation of bulk-separated oligodendrocytes into the brains of shiverer mutant mice: immunohistochemical and electron microscopic studies on the myelination

Normal oligodendrocytes were separated from 7-day-old mouse (BALB/c) brains by the Percoll gradient method. Immunohistochemical staining with an anti-galactocerebroside serum revealed that about 85% of the separated cells were oligodendrocytes. The oligodendrocytes were transplanted into the corpus striatum of 4-week-old shiverer mutant mice which are characterized by the lack of myelin basic protein (MBP). Myelination by the implanted oligodendrocytes was investigated immunohistochemically and electron microscopically 6 weeks after the operation. Certain areas in the corpus striatum were intensely stained with antiserum to MBP. Electron microscopic examination showed that some axons were surrounded by normal type myelin sheaths with major dense lines. These results clearly indicate that matured oligodendrocytes are able to survive and myelinate the host axons even in the adult brain.

Echocardiographic detection and treatment of intraoperative air embolism

A real-time two-dimensional echocardiogram was used to detect the presence of an air embolism in patients undergoing neurosurgical procedures in the sitting position. The technique could with good sensitivity detect the appearance of a single air bubble intraoperatively, thus allowing early intervention to prevent development of further air emboli. Two types of air embolism could be differentiated; the single-bubble type and the "stormy-bubble" type. The single-bubble type was observed during skin and muscle incisions, craniotomy, and brain lesion excision. Further embolism development was prevented by electrocoagulation and application of bone wax. The stormy-bubble type occurred during dura and muscle incisions and was prevented by electrocoagulation, reflection of the dura, or suturing the affected muscle. The routine use of a Swan-Ganz catheter for removal of air embolism by suction proved effective for the treatment of the stormy-bubble type of air embolism. Masking the operative field with saline-soaked cotton strips was of moderate benefit in the stabilization of the single-bubble type of air influx, but proved to be of little value in controlling the entrance of the stormy-bubble type.

Facial nerve function after surgery for removal of acoustic neuroma by the extended middle cranial fossa approach

Postoperative facial nerve function was evaluated in 98 patients operated on by the middle cranial fossa approach or the extended middle cranial fossa approach from June 1976 to April 1985. In this series, the smaller the tumor size at the time of the initial surgery, the better the postoperative facial nerve function was. The facial nerve was preserved in 83.4% of the 79 patients who were subjected only to the initial surgery. However, total removal of the tumor along with facial nerve preservation was achieved only in 70.8%. Anatomical preservation of the facial nerve was possible in 78% of 87 patients. The postoperative functional results among patients in whom facial nerves were anatomically preserved were satisfactory (facial expression score of 75% or higher, i.e., 30 points or more out of a possible 40 points) in 70-80% of the patients with small size or intracanalicular tumors, but, in less than 50% of the patients with tumors of medium size or larger. There is a need to obtain higher rates of functional preservation as well as higher rates of satisfactory functional results. At the present stage, we must strive to achieve earlier diagnosis so that surgery can be performed while the tumor is still medium-sized or small.

Results of surgery by the modified extended middle cranial fossa approach in 100 patients with acoustic neuroma

The results of surgery by the middle cranial fossa (MCF) approach or the modified extended MCF approach in 100 patients with acoustic neuroma are reported. The rates of facial nerve preservation, tumor removal, and hearing preservation were reported and discussed. This surgical procedure can be applied to tumors of any size, from tumors confined to the internal auditory canal to those extending into the posterior fossa.

Transpetrosal approach for aneurysms of the lower basilar artery

Extradural subtemporal access to the petrosal ridge and a resection of the anterior pyramidal bone produced direct observation of the lower basilar artery, with minimum retraction of the temporal lobe and preservation of the temporal bridging veins. Two patients with lower basilar trunk aneurysms facing toward the brain stem, were operated on by the "transpetrosal approach," with successful clipping of the aneurysms. Auditory function was preserved in one case. This approach decreases the possibility of retraction damage to the temporal lobe, brain stem, or cranial nerves, and may be helpful for surgery of aneurysms arising around the vertebrobasilar junction or at the origin of the anterior inferior cerebellar artery.

Trigeminal neuralgia and hemifacial spasm caused by a tortuous vertebrobasilar system

The case of a 66-year-old woman who developed both trigeminal neuralgia and hemifacial spasm caused by a tortuous vertebrobasilar system is reported. Vertebral angiography showed a dilated and elongated basilar artery overlying the porus acusticus of the internal auditory canal. Double-contrast computed tomography scanning was very useful in evaluating this abnormality. Vascular decompression was performed by using a fenestration clip.

Extraneural metastasis of choriocarcinomatous element in pineal germ-cell tumor. Case report

A case of pineal germ-cell tumor producing human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP) is reported in a 23-year-old man. Extraneural metastasis developed during a course of combined chemotherapy after radiation therapy. Postmortem examination revealed that the metastatic pulmonary tumor was a choriocarcinoma, producing only HCG.

[Subfrontal schwannoma: report of a case]

Subfrontal schwannoma is extremely uncommon. By reviewing the literature, we are able to find 8 previously described cases. This report describes a very rare case of solitary schwannoma grown in the anterior cranial fossa. A patient, 23 years old male, had experienced generalized convulsion on April 4, 1981. On the Tc99m scintigram, accumulation of isotope was observed in the left anterior cranial fossa. The carotid angiography revealed that the tumor stain was supplied from ophthalmic artery and orbitofrontal artery. CT showed an area with relatively low density in the left frontal base. This area was well enhanced following contrast injection. Coronal CT revealed that the tumor was contiguous with the left olfactory groove. The tumor was removed on May 12, 1981. The left fronto-temporal post-operative epidural hematoma was observed after the operation but his post-operative course was relatively satisfactory. Histological section of tumor showed interwinning bundles of cells with pallisading on hematoxylin and eosin. Pathological study showed such pallisading of the tumor cells, which confirmed that the tumor was schwannoma. While the precise origin of this unusually situated schwannoma remains uncertain, it appears most likely that the origin was from either ectopic, or perivascular nerve plexus schwann cells or dural branch of trigeminal nerve. Because the branch of the trigeminal nerves or anterior ethmoidal nerves is distributed to the meninges, the trigeminal nerve is covered with schwann cells after penetrating the pia mater in the anterior cranial fossa.(ABSTRACT TRUNCATED AT 250 WORDS)