Gynecomastia and ectopic human chorionic gonadotropin production by transitional cell carcinoma of the bladder

We report a patient with gynecomastia and ectopic production of human chorionic gonadotropin (HCG) by a transitional cell carcinoma of the bladder. In the present case, serum HCG levels and gynecomastia paralleled the clinical course. On admission, the patient was suffering from invasive transitional cell carcinoma (grade 3) of the bladder with metastasis to the left inguinal lymph nodes, together with gynecomastia. The serum HCG level was also elevated. After anticancer chemotherapy, the apparent bladder lesion and gynecomastia disappeared, and the serum HCG level declined to within normal limits. About 2 months after discharge, when the patient suffered from recurrent invasive tumors of the bladder, gynecomastia reappeared and the serum HCG level again became elevated. beta-HCG was demonstrated in biopsy tissue using the immunoperoxidase technique. The presence of beta-HCG was always focally demonstrated and was shown to be localized in the cytoplasm of the tumor cells.

Stereotactic mesencephalotomy for pain relief. A plea for stereotactic surgery

Rostral mesencephalic reticulotomy (RMR) for pain relief was performed in 34 patients with intractable pain. Most of these patients have been followed for a long period of time postoperatively, the longest follow-up period being 11 years. Contrary to the commonly prevailed bias in the past that mesencephalotomy may be a surgical intervention with potential risk, these patients of RMR have continued to substantial improvement postoperatively in terms of their preoperative intractable painful dysesthesia after a long period of time. The results of pain relief for denervation pain as well as for nondenervation pain are surprisingly good even after unilateral procedures. There was no operative mortality. Postoperative disturbance of ocular motility has been reduced. RMR has its scientific basis in that the medial part of the reticular formation rather than the classical lateral spinothalamic tract has more significance in the central conduction of nociceptive impulses through the midbrain level, which was verified by intraoperative neuronal recording with a tungsten microelectrode. The present report emphasizes that stereotactic mesencephalotomy, if performed meticulously and precisely, is a safe surgical procedure for pain relief. Results of MRI and sensory manifestations of a patient 11 years after RMR are also presented.

Subcostal transabdominal incision with midline extension for tumors of the kidney, adrenal gland or retroperitoneal cavity

Subcostal transabdominal incision with midline extension is excellent for removal of large renal or adrenal tumors, or bilateral or retroperitoneal tumors. This incision is simple and gives a wide surgical field without involving the pleural cavity. No troublesome complications resulting from this approach have occurred.

The advantage of enzyme-linked immunosorbent assay (ELISA) as a method of microbiological monitoring for rat virus (RV)

An enzyme-linked immunosorbent assay (ELISA) was tested to detect antibodies against rat virus (RV). The purified ELISA antigens were prepared from rat embryonic cells infected with RV-13 (prototype strain) and UT-2 (Japanese isolate), respectively. Western blotting analysis confirmed that both of these antigens had three structural polypeptides (81 K, 61 K, and 59 K). Eleven laboratory and wild rat colonies in Japan were tested for rat virus contamination, serologically. No significant differences in the sero-positive ratio and the distributions of ELISA titers were demonstrated in the ELISA, using antigens from RV-13 and UT-2. ELISA was more sensitive and specific for detecting antibodies against RV from rat serum rather than hemagglutination inhibition (HI) test. This study also confirmed that the RV contaminated widely in colonies of laboratory and wild rats in Japan, and suggested that RV would have to be checked during the microbiological monitoring of laboratory rats.

[CT-guided stereotactic surgery of brain abscess]

Seven patients with brain abscess underwent CT-guided stereotactic aspiration using Iseki's stereotactic apparatus. Three of them were under the age of fifteen and four were older than thirty. The lesions were single and round in four cases, multilobular in two and multiple in one patient. Operations were performed after systemic administration of antibiotics for more than two weeks and after capsule formation was confirmed on CTs. Preoperative volume of the abscesses was estimated from CTs. The target point chosen was the center of the ring of the largest diameter in the enhanced lesion. Abscess was aspirated under monitoring with intraoperative CT scan. No continuous drainage was performed and no antibiotics were given directly into the abscess cavity. In all cases the center of the abscess was punctured with a single trial. Average volume of the preoperative brain abscesses was 18.8ml. Aspirated volume at the time of the operation averaged 16.9ml and all the abscesses decreased to unmeasurable size on CTs. In five of seven patients abscesses were cured after a single aspiration, and in one case after the second operation. One case required extirpation of the lesion. During the follow-up period of four months to five and a half years six patients showed no recurrence. One patient died of unrelated cause four and a half years after the operation. No operative complication was noted. There was no operative morbidity or mortality. Using a CT guided stereotactic method, brain abscess is punctured so accurately, regardless of its location and size, that damage to the surrounding brain during operation can be minimized. Therefore it is highly possible to aspirate abscesses completely.(ABSTRACT TRUNCATED AT 250 WORDS)

Bilateral versus unilateral percutaneous high cervical cordotomy as a surgical method of pain relief

The present report is concerned with the results of bilateral percutaneous high cervical cordotomy (60 patients) compared with those of unilateral cordotomy (161 patients). The result of pain relief is classified into 4 grades based on Hitchcock's criteria; grade 1: complete pain relief, grade 2: almost complete pain relief with slight residual pain, grade 3: persisting pain, but tolerable, grade 4: persisting pain, untolerable. In cases of bilateral cordotomy (60 patients), 76% of the cases showed grade 1, 19% being grade 2, 3% being grade 3 and 2% being grade 4. On the contrary, the unilateral cordotomy (161 patients) showed less impressive results, particularly in grade 1, namely, grade 1 being 64%, grade 2 being 18%, grade 3 being 14% and grade 4 being 4%. Clinically acceptable results (grade 1 plus grade 2) were, therefore, obtained in bilateral cordotomy (95%) as compared with unilateral cordotomy (82%). The difference in pain relief between bilateral and unilateral procedure observed in the present investigation is contrary to that reported previously by others. The possible explanation for less impressive result in regard to grade 1 of unilateral cordotomy is that unilateral cordotomy was performed in this series to alleviate the major side of patient's pain, followed by latent pain on the other side postoperatively, which is not uncommon phenomenon in cancer pain. Whereas all of the bilateral cordotomies were done either for midline pain or bilateral pain, unilateral cordotomy gave satisfactory pain relief in some cases of midline pain. Midline pain, therefore, does not necessarily require bilateral cordotomies from a clinical point of view.(ABSTRACT TRUNCATED AT 250 WORDS)

An ultrasound-guided stereotactic apparatus for intracranial mass lesions

One of disadvantages of conventional stereotactic operation for intracranial mass lesions is that it is basically a blind procedure even if the operation is performed in a gantry of a CT scan. High resolution ultrasound image gives real-time information on intracranial pathology such as bleeding, remaining cyst fluid or haematoma. The authors report an ultrasound guided stereotactic apparatus which gives real-time images of the lesion during operation.

[A new apparatus using the Micro Ultra-Sonic Aspirator (MUSA) system for microneurosurgery]

Matsumoto was the first to present the NIIC UltraSonic Aspirator for CT guided stereotactic aspiration of intracerebral hematoma. Based on the NIIC Aspirator, the authors have developed a useful tool for microsurgery by adapting conventional ultrasonic aspirators. This was done by making the aspirator lighter and more handy for use during microsurgical procedures. A newly devised apparatus using the Micro Ultra-Sonic Aspirator (MUSA) was applied clinically to surgical treatment for brain tumors, arterio-venous malformations (AVMs) and intracerebral hematomas. Using the MUSA system, it became easier to remove successfully tumorous mass and the nidus of AVM, because it minimized the risk of injury to the normal structures such as the surrounding brain tissue, vascular systems and the cranial nerves.

Thyroid functions before and after maintenance hemodialysis in patients with chronic renal failure

To study the factors involved in the low thyroid hormone levels in patients with chronic renal failure (CRF), we investigated thyroid functions just before and after hemodialyses (HD) in 32 such patients who were on maintenance HD. In addition, we measured serum thyroid hormone binding inhibitor activities (THBI) in another set of 37 patients. None of the patients had been suspected of having thyroid diseases. HD duration and aging did not have a significant effect on the results of the thyroid function tests. Before each HD, the serum concentrations of T3, T4, FT3, FT4, rT3, PBI, FT3I, FT4I, FT3/T3, FT4/T4, T4/TBG, T4/TSH and FT4/TSH were lower, and those of TSH, TBG, and thyroglobulin (Tg) were higher in the patients than in normal controls. The thyroid hormone concentrations were negatively correlated with the BUN and creatinine levels. The Tg levels were positively correlated with the BUN levels. After each HD, almost all the thyroid function tests including T4/TBG ratio showed improvements, which indicated that hemodilution and a decrease in the T4-binding affinity of TBG with thyroid hormones were the major factors in the low thyroid hormone levels in CRF patients. However, even after HD, T3, FT3, rT3, T4/TSH and FT4/TSH were still lower and TSH and Tg were still higher in the patients. These data suggested that the CRF patients were in a subclinical hypothyroid state. THBI was high in patients with CRF and did not change following HD. NEFA did not seem to contribute to the high THBI before HD, because they were in the normal range. However, as NEFA became very high after HD and possessed THBI, we calculated the corrected THBI (C-THBI) by subtracting the effect of NEFA from total THBI. C-THBI was high before HD and decreased after HD. Therefore, it was suggested that this C-THBI contributed to the abnormalities in the affinity of TBG with thyroid hormones. From these studies, it is concluded that (1) the patients with CRF may be in a subclinical hypothyroid state, although hemodilution was seen to have a strong effect on the thyroid hormone concentrations, and (2) C-THBI may have an effect on the affinity of TBG with thyroid hormones and play an additional role in low thyroid hormone levels in these patients. The mechanisms of hypothyroidism and the nature of C-THBI remain to be clarified.

[Development of a highly sensitive assay for serum thyroglobulin using avidin-biotin system and its clinical application]

The authors have developed a highly sensitive sandwich-type enzyme immunoassay (EIA) for serum thyroglobulin using the biotin-avidin system. The sensitivity of this EIA was 0.1 ng/ml. The intra- and inter-assay coefficient of variation was 4-15% and 4-11%, respectively. Human Tg in serum was detectable in 100% of 63 normal subjects, and the normal range was from 2.3 ng/ml to 47.4 ng/ml. The recovery rate was very good. Then we applied this EIA to the follow-up study of patients with thyroid cancer. Serum Tg levels were serially determined in 15 patients with thyroid cancer who had undergone thyroidectomy (n = 9 subtotal, n = 6 total) and were receiving thyroid hormone suppression therapy. It was found that there were three groups in regard to the relationship between serum TSH and Tg. The first group showed normal TSH and normal Tg levels (n = 4). The second group showed TSH levels that were lower than the lower limit of the assay, whereas Tg levels were within the normal limit (n = 5). The last group showed both TSH and Tg that were lower than the lower limit (n = 6). In one case in the last group, recurrence of thyroid cancer was forecast by the change of Tg levels (from below 0.1 ng/ml to 5.9 ng/ml). Therefore, it is important to suppress serum Tg and TSH levels as much as possible in order to obtain the best usefulness of serum Tg determination in the follow-up study of thyroid cancer in patients who have undergone subtotal thyroidectomy or have residual thyroid tissue. We also measured Tg levels in patients with untreated Graves' disease. Twelve patients were negative for anti-Tg antibody and 18 were positive for anti-Tg antibody. Even in the antibody positive cases, serum Tg could be detected and their levels could be calculated from the recovery studies. The mean serum Tg levels in antibody positive cases were lower than in negative cases. These studies showed that our sensitive EIA for serum Tg determination was useful in practice in patients with thyroid disease.

Dialysis dysequilibrium syndrome in neurosurgical patients

Four neurosurgical patients with acute renal failure are presented. Intracranial pressure (ICP), cerebrospinal fluid (CSF) osmolality, and plasma osmolality were measured before, during, and after hemodialysis. There was an increase in ICP during all six hemodialyses performed on these patients. An osmolality gradient was established between the plasma and the CSF during four hemodialyses performed on two patients but not during one hemodialysis on one other patient. Continuous ventricular drainage and ICP monitoring were simple and effective clinical methods to avoid irreversible herniation during hemodialysis in these patients. A review of the literature on, proposed pathogenesis of, and prophylactic possibilities for dialysis dysequilibrium syndrome in neurosurgical patients is presented.

[EEG topographic changes of brain abscesses in children]

EEG topography was investigated before and after surgical treatment in 4 patients with brain abscess aged from 5 to 13 years. According to the recording technique designed by Matsuoka and Ueno, the recorded EEG for each 5 seconds was analyzed to obtain square roots of power spectra for each band of delta (2-3.8 Hz), theta (4-7.8 Hz) and alpha (8-12.8 Hz) which were then added for the 60-seconds duration of each trial. After that, numerical matrix presenting the topographic distribution of spectral energy of each band were constructed and displayed as color images. In addition, the EEG topographies of brain abscesses were compared with the CT scans simultaneously obtained. In all of four cases before surgical treatment of the brain abscess, the location of the focal delta wave on the EEG topography was more closely related to the site of brain abscess comparing with its correlation between the location of the delta focus on the conventional EEG and the site of brain abscess. In contrast, as for the theta wave, there was no prominent correlation to the site of the brain abscess. In the early stage of 10-15 days after aspiration of the brain abscess, the most characteristic change of the EEG topography was an approximately 25% reduction of the maximum equivalent voltage of delta band with associated disappearance of the sharply located focal delta wave being noted before aspiration.(ABSTRACT TRUNCATED AT 250 WORDS)

[CT-guided stereotactic brachytherapy in deep-seated malignant gliomas--interstitial irradiation by double-catheter after-loading method]

CT-guided stereotactic brachytherapy has been performed for the deep-seated malignant gliomas using the double-catheter after-loading method. The catheter system consists of two coaxial polyethylene tubes with closed tips. The outer catheter is 3.0 mm in outer diameter and 2.4 mm in inner diameter. The inner catheter is 2.0 mm in outside diameter and 1.4 mm in inside diameter, and contains the radioactive sources. Localization of the target volume is determined by the preoperative findings of computed tomography (CT), magnetic resonance imaging (MRI), and cerebral angiography. Dosimetry and dose planning are so finalized for the target volume as to be irradiated interstitially more than tumoricidal dose. After stereotactic biopsy of the deep-seated brain tumors, stereotactic implantation of the outer catheters is performed using Iseki Stereotactic System in the CT room. Burr holes had been previously opened in the operating room. The inner catheters containing nonradioactive sources (dummy sources) are inserted, and skull X-p is taken to confirm the position of the dummy sources, and to calculate the dosimetry by computer. The inner catheters are replaced with catheters containing radioactive sources (226Ra) in the irradiation room. 226Ra sources deliver at least 500 rads/day (approximately 20 rads/hr) to the target volume as interstitial irradiation. Two patients of malignant gliomas treated with this procedure were shown as representative cases. These patients underwent CT-guided stereotactic brachytherapy as "boost" combined with conventional external irradiation.(ABSTRACT TRUNCATED AT 250 WORDS)

Spontaneous in vitro production of thyroglobulin specific helper factor in patients with autoimmune thyroid diseases

We have investigated regulatory cell abnormalities in patients with autoimmune thyroid diseases through in vitro thyroglobulin (Tg) specific helper factor production. Helper activities were measured in the mice spleen cell assays, using hapten-carrier system. Peripheral blood leukocytes (PBL) from 5 out of 6 patients produced the Tg specific helper factor not only when they were stimulated in vitro with Tg but also when they were not stimulated. On the contrary, normal PBL did not produce the factor when they were not stimulated in vitro. However, 3 out of 5 normal PBL did produce the factor when they were stimulated in vitro with Tg. From several lines of studies, this helper factor was specific for Tg in its production and action. From these results it is concluded that (a) Tg specific helper T cells are already activated in vivo in patients with autoimmune thyroid diseases, indicating the presence of immunoregulatory abnormalities in these patients, and that (b) normal PBL have a potential to produce this helper factor when they are appropriately stimulated.

Short latency somatosensory-evoked potentials--direct recording from the human midbrain and thalamus

Short latency somatosensory-evoked potentials were recorded from the human thalamus and the midbrain during stereotactic operations. Several subcomponents were recognized on the peak of N18. These were recorded with maximal amplitude at the border between the caudal portion of the thalamus and the rostral midbrain. Two positive-negative responses, not previously shown, were observed between P14 and N18. These responses were prominent in the rostral midbrain. These findings indicate that the ascending phase of N18, and the N18 itself, are the compound potential generated in the mesodiencephalic junction.

Surgical treatment of hypertensive intracerebral haematoma by CT-guided stereotactic surgery

Ninety consecutive cases of hypertensive intracerebral haematoma were treated with CT guided stereotactic evacuation. The patients were composed of 61 males and 29 females, ranging from 42 to 87 years old. The location of haematoma was either in the putamen (59 cases) or in the thalamus (31 cases). The average volume of the evacuated haematoma was 21.4 ml in the putaminal haematoma and 14.0 ml in the thalamic haematoma. Postoperative follow-up study in 46 patients showed good recovery of neurological deficits both in putaminal and thalamic group. Criteria of surgical indication of CT-guided stereotactic evaluation of intracerebral haematoma were advocated based on the author's clinical experience.

Spontaneous autoimmune thyroiditis in Bio Breeding/Worcester (BB/W) rat

We investigated the serial changes in the plasma levels of anti-thyroglobulin antibody (ATA) by solid-phase enzyme immunoassay, thyroid hormones and blood glucose, since spontaneous occurring lymphocytic thyroiditis (LT) has been found in spontaneously diabetic Bio Breeding/Worcester (BB/W) rat. We also observed the correlation between these levels and histological findings in the thyroid gland. The incidence of diabetes was 0% in 5 week old rats (group A), 70% in 11 week old rats (group B), and 86% in 20 week old rats (group C), while LT was observed in 0% in group A, 20% in group B and 48% in group C. Although the incidence of both increased with age, there was no link between LT and diabetes. Plasma ATA levels were 91.4 +/- 28.5 (OD492 X 1,000, mean +/- SEM) in the control (14 week old Wistar Furth) rats. 49.5 +/- 15.4 in group A, 197.8 +/- 41.5 in group B, and 376.7 +/- 48.7 in group C, again showing a clear increase with age. In group C, the plasma levels of ATA in rats with LT were significantly higher than those without LT. In addition, 6 out of 11 rats without LT had abnormaly high ATA levels. In group C, the plasma levels of free 3,5,3'-triiodothyronine (FT3) and total thyroxine (TT4), and also the FT3/TT4 ratio were significantly lower and the plasma levels of blood glucose were higher than in the other groups. There was no difference between the plasma thyroid hormone levels in rats with LT and those without LT. These studies suggest that LT may occur independently of insulitis, namely diabetes, ATA levels and the incidence of LT increase with age, the site of ATA production may not be confined to the thyroid gland, and the derangement of glucose metabolism may be one of the factors in the decrease in plasma thyroid hormone. The BB/W rat is not only a useful animal model to use in exploring the pathogenesis of human insulin-dependent diabetes mellitus, but also spontaneous autoimmune thyroiditis.

Decreased serum thyroglobulin levels in the late stage of pregnancy

Serum thyroglobulin levels were serially measured in 25 normal pregnant women to evaluate thyroidal activity during normal pregnancy. Measurements included serum T3, T4, free T4, TBG, and TSH. Tg and FT4 levels were found to be decreased in the third trimester when compared with those of the first trimester and with those of normal non-pregnant individuals (P less than 0.01). TSH levels were higher than normal in pregnant women at all stages of pregnancy, with a significant rise at the third trimester. These findings suggest the presence of a subclinical hypothyroid state in the late stage of normal pregnancy.

[Chronological changes in the blink reflex and MRI in a patient with lateral medullary infarction]

Recently, the brainstem pathways of bilateral late reflexes (R2) of electrically elicited blink reflex have been well established. An afferent delay or block of the late reflexes is closely related to a lesion of the lateral medullary portion. The chronological alteration of blink reflex (BR) was studied to compare with radiological abnormalities on MRI in a patient with lateral medullary infarction on the right side. A diagnosis of Wallenberg syndrome was made clinically and location of the lesion was identified in detail by MRI. The infarcted region which was well demonstrated as an increased intensity area on SE images obtained 52 days after the onset of symptoms was much smaller than that on SE as well as on IR image 21 days after the onset of symptoms. Therefore, it was concluded that more than half of the increased intensity area on the SE images obtained 21 days after the onset of symptoms recovered from the condition of being extremely damaged by ischemia on the right lateral medullary portion in this patient. On the other hand, in the initial BR 26 days after the onset of symptoms, the late reflexes (R2) were consistently absent bilaterally when the affected side (right) was stimulated and normal when the normal side (left) was stimulated. This type of BR abnormality is compatible with an afferent block of late reflexes (R2). The early reflex (R1) was normal on either side. Whereas in the second BR at 55 days after the onset of symptoms, the late reflexes turned to be normal in latency when the right side was stimulated.(ABSTRACT TRUNCATED AT 250 WORDS)

Interference with thyrotropin receptor antibody determination by a spuriously occurring anti-bovine TSH antibody

Abnormally negative values of thyrotropin binding inhibitor immunoglobulin (TBII) were found in the sera from a patient with Graves' disease. This was due to the presence of potent bovine TSH (bTSH) binding activity in the sera. This activity was demonstrated to be in immunoglobulin G (IgG) with a lambda light chain isotype, which was shown to have an affinity for bTSH with a Ka value of 3.5 X 10(10) M-1 and a maximum binding capacity of 1.1 X 10(-14) M/mg IgG. F(ab')2 fragments obtained through pepsin digestion from the patient's IgG retained bTSH binding activity. [125I] bTSH binding to this IgG was inhibited by the TSH receptor. The inhibition was not completely competitive, suggesting the presence of different binding sites for this IgG and the TSH receptor on the TSH molecule. This IgG, however, could not bind labelled human TSH (hTSH). Since neither TSH nor other pituitary derivatives had ever been given to the patient, this bTSH binding activity was considered to be due to a spuriously occurring anti-bTSH antibody.

[A new treatment of hypertensive intracerebral hematoma--a follow-up study on 46 patients with hematoma treated by CT guided stereotactic method]

During the last 2 years, 46 cases of hypertensive intracerebral hemorrhage in the basal ganglia were treated by CT guided stereotactic aspiration and their outcome was evaluated in terms of the rate of hematoma removal, the change of consciousness level and the recovery of motor and sensory functions. They are aged from 45 to 79 years old, the average 56, and aspirated 1 to 24 days after the onset, two third of them being within 1 week. The whole procedure was done in the CT room under direct CT guidance and by one trial. In putaminal type hemorrhage, the removed hematoma volumes ranged from 9 to 48 ml, average being 23.7 ml, in thalamic type from 5 to 29 ml, average being 15.5 ml. The average rate of removal was 81.1% in 30 cases within 1 week. In most cases, preoperative consciousness was not severely disturbed, in putaminal type, 19 were alert or confused, 4 somnolent, 5 stuperous and in thalamic type, 6, 6, 3 respectively and 2 were semicomatous, one of them had herniation sign. In putaminal type all but 2 cases recovered to alert or confused state, the first one had postoperative bleeding and the other was already apallic preoperatively. In thalamic type, we lost 3 cases, 2 by gastrointestinal bleeding and 1 DIC, by rehemorrhage 2 months after the operation. All but one who was semicomatous preoperatively recovered to alertness. In motor function, some cases of the putaminal bleeding with intact internal capsule remained hemiplegic. On the other hand, most of the cases with partial destruction of the internal capsule on CT recovered well in both types of hematoma.(ABSTRACT TRUNCATED AT 250 WORDS)

[Influence of hemisphere lesions on the contralateral blink reflex]

Electrically elicited blink reflexes were investigated in 28 patients with unilateral hemispheral lesion. The reflex evoked by electrical stimulation of the supraorbital nerve contralateral to the side of the hemispheral lesion was absent or depressed in 14 out of 28 cases. The abnormal patterns of the blink reflexes were devided into four different types (Type AB, Type AD, Type EB, and Type AB-EB). The Type AB, recorded in 4 cases, consisted of bilateral absence of late component (R2) when the supraorbital nerve on the non-lesion side was stimulated. In contrast, the reflex responses were almost normal bilatarally when the stimulus was applied to the nerve on the lesion side. The Type AD was observed in 2 cases. When the stimulus applied on the non-lesion side, both ipsilateral and consensual R2 were markedly delayed in latency. The Type EB was seen in one case. In this type the absence of the late component (R2) was confined to the clinically affected side independent of the side of stimulation. The Type AB-EB was observed in 4 cases. This type consisted of bilateral absence of R2 component after stimulation on the non-lesion side as seen in Type AB. However, when the stimulus applied on the lesion side, R2 component was only elicited on the ipsilateral side of stimulation. Based on our results, the authors emphasize that abnormality of the contralateral blink reflex in the patients with unilateral hemispheral lesion showed not only Type AB or Type AD but also Type AB-EB which may indicate lowered excitability of bulbar lateral reticular formation of the lower brain stem as well as spinal trigeminal system. This type was presumably due to loss of facilitatory influences associated with the contralateral hemispheral lesion, closely correlated with the lower postcentral region advocated by Ongerboer de Visser.

[Significance probability mapping of brain electrical activity--its problem and specified z-statistic mapping]

Significance probability mapping (SPM) of brain electrical activity first described by Duffy et al. is useful tool for studying functional aspects of brain disease. Z-statistic SPM is able to identify the area of brain electrical activity deviated with statistic significance from the control group. The problem of this method is, however, that the nature of deviation, i.e., whether it is increase or decrease of electrical activity, can not be displayed. From this point of view, we attempted to use modified z-statistic method. Statistically deviated region and its nature can be clearly displayed on the same picture by analyzing EEG with this method. This method can be applied to SPM of evoked potentials. SPM is not yet complete method for the assessment of brain electrical activity, but there is much room for adopting other statistic method that is more suitable for the aim of the study. Functional aspects of the brain will be more readily clarified by the use of modified SPM and by combination with findings of CT scan, NMR and PET that can give morphological and metabolic information.

[Ascending limb of the N20 component of somatosensory evoked potential--an analysis on direct recording from the human midbrain]

Somatosensory evoked potential elicited by median nerve stimulation at the wrist was recorded from five loci on the trajectory of stereotactic rostral mensencephalic reticulotomy. Four distinct positive waves followed by one negative wave, the peak latency being 16.3 msec, were recorded from the rostral midbrain reticular formation near the medial lemniscus. The four positive waves were named as I, II, III, and IV respectively. Peak latency of these positive waves was 12.6, 13.7, 14.7 and 15.8 msec respectively. The first two positive waves (I, II) corresponded to P13 and P15 recorded over the scalp. The other two positive waves (III, IV) changed their polarity to negative at the level of the ventral thalamus and formed the ascending limb of N20 recorded over the scalp. N16 was most prominent at the level of nucleus ventrocaudalis externus. These findings suggest that the ascending limb of N20 is composed of at least three components, wave III, IV, and N16. The present report is compatible with the investigations by Abbruzzese et al.2) and Eisen et al.11) that there are several distinct dipoles between P15 and N20 of somatosensory evoked potential in man.

Long-term follow-up study of rostral mesencephalic reticulotomy for pain relief--report of 34 cases

A long-term follow-up study of rostral mesencephalic reticulotomy (RMR) for pain relief is presented. 34 patients (24 males and 10 females) were operated. Ages ranged from 18 to 65 years. The follow-up period was 1-70 months. The overall effectiveness of RMR showed good relief of pain in 23 patients (67%). The study of effectiveness of RMR according to type of pain showed good relief of pain in 5 out of 6 patients (83%) with nondenervation pain, whereas satisfactory pain relief was obtained in 18 out of 28 patients (64%) with denervation pain.

Scavenging of chlorpromazine cation radical by ascorbic acid or glutathione

The report presented here demonstrates that scavenging of chlorpromazine cation radical (an absorption maximum = 530 nm) by ascorbic acid or glutathione can be kinetically and stoichiometrically analyzed at pH 1.5 but not at pH 3.0 and 6.0 using a conventional absorption spectrophotometer. The cation radical decays spontaneously about 10 and 200 times faster at pH 3.0 and 6.0, respectively, than at pH 1.5. At pH 1.5, ascorbic acid scavenges the cation radical faster than glutathione does, and the following different scavenging mechanisms are postulated from the above kinetic and stoichiometric analysis. The reaction of the cation radical with ascorbic acid is second order. The ascorbic acid free radical, which decays mainly by dismutation, is generated by the bimolecular reaction. In the case of glutathione, on the other hand, about 70% of the scavenged cation radical disappears through free radical chain reactions that glutathione thiol anion and glutathione free radical probably initiate. The remaining (about 30%) disappears by conjugation with glutathione. It may be due to relative nonreactivity of ascorbic acid free radical that free radical chain reactions, found commonly in radical chemistry, do not occur in the scavenging reaction by ascorbic acid. Based on the above results, the physiological scavenging mechanisms of the cation radical by the two reducing substances are discussed briefly.

[An assessment of outcome prediction in patients with severe brain damage with auditory brainstem response and blink reflex]

Results of auditory brainstem response (ABR) and electrically elicited blink reflex (BR) recorded from 43 patients with severe brain damage within three days after the onset of illness were analyzed to assess the prognostic value of ABR and BR with respect to patient outcome evaluated by the criteria proposed by Jennett and Bond. It was possible to recognize, in recordings obtained from patients with severe brain damage, three basic patterns of BR as well as five patterns of ABR within three days after the onset. Three basic patterns of BR were composed of Type I, which closely approximated the BR of normal subjects except for moderately prolonged latency of R2, Type II, which indicated absence of bilateral R2 activities, and Type III, which showed absence of R1 as well as bilateral R2. ABRs were graded, in increasing order of abnormality, from Type I to Type V. Type I was almost normal pattern from wave I to wave V. Type II indicated prolonged latency or markedly reduced amplitude of waves IV and V. Type III showed absence of waves IV and V. Type IV had only wave I. Type V indicated absence of all waves. BR abnormalities significantly proved useful in predicting vital prognosis of the comatose patients with supratentorial lesion. In patients who had Type II of BR, additional studies of ABR enhanced the reliability of prediction of functional prognosis. On the other hand, ABR was recognized as stronger basis for predicting outcome in patients with infratentorial lesion. All patients with Type IV or Type V of ABR were expired within one month after the onset.(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluation of anticonvulsant-induced bone changes by a microdensitometric method]

The effect of long-term anticonvulsants on bone change was evaluated by microdensitometric method (MD method) in 221 outpatients of Neurological Institute Tokyo Women's Medical College. Laboratory findings including serum Ca, P, Al-p were compared with severity of bone change. Following results were obtained; In 221 patients, 159 cases (72%) were normal, 31 cases (14%) were in the initial stage of abnormality, 23 cases (10%) in grade I, 7 cases (3%) in grade II and one case (1%) in grade III of abnormality. Incidence of abnormality was high in the age of 26-35 years old and in the age over 56 years old. Total dose, serum concentration of diphenylhydantoin (DPH) as well as phenobarbital (PB) and also duration of administration of PB correlated positively with severity of bone change. Duration of administration of DPH and valproic acid (VPA), total dose and serum concentration of VPA did not correlate with severity of bone change. Serum Ca correlated with severity of bone change, but P and Al-p did not correlate with severity of bone change. Pattern of bone change was estimated by two parameters of MD method (MCI and GSmax). Results showed that most of the osteopathy (grade I-III by MD method) fell into osteoporotic type. Based on these results, it is suggested that roentgenologic and biochemical supervision of the patients is required during long-term anticonvulsant therapy.

[A new apparatus and stereotactic method for percutaneous high cervical cordotomy]

The authors devised a stereotactic apparatus for percutaneous cordotomy based on the experience of 191 percutaneous high cervical cordotomies on 150 patients suffering from intractable pain. This apparatus has two major components. One is a head and neck holder and the other is a guide and marker system. The head and neck holder contains fixed neck holder and head holder which can be movable in vertical direction. Using these holders, the operator can keep the patient's neck in neutral position. The marker system contains two markers of origin and a 10mm scale which indicates center line as well. The guide system, stereotactically designed, is movable in three direction and acrylic guide groove is attached. The guide needle for percutaneous cordotomy is inserted along the guide groove. The guide and marker system can be attached in both sides of the head and neck holder, therefore, the operator can insert the needle in both sides of the patient. This apparatus makes it possible to locate the target stereotactically for percutaneous cordotomy, since location of the inserted needle can be determined with the aid of cervical X-ray, even if there is no image intensifier of TV display screen available. Therefore it can be possible to reduce the X-ray exposure of the patient.

A new apparatus for CT-guided stereotactic surgery

Combining whole-body CT scan with a stereotactic system, the authors have developed and applied clinically an apparatus which readily provides intraoperative CT images, making it possible to confirm the location of the target point and ascertain the intraoperative environment. It takes about 9 s to obtain a CT image. Our purpose is to make stereotactic surgery, a kind of blind surgery, as safe and reliable as a visualized procedure by intraoperative CT scanning. By the method, in which there is very little invasion under local anesthesia, evacuation of deep-seated intracerebral hematomas as well as brain abscesses and also biopsy or brachytherapy of brain tumors in the brain can be done with safety and reliability.

Cerebral-evoked responses elicited by direct stimulation of the lateral spinothalamic tract in the human

The authors recorded cerebral-evoked responses elicited by direct stimulation of the human lateral spinothalamic tract (LST) during percutaneous cordotomy to investigate central conduction of noxious stimuli. These responses consisted of four negative potentials, peak latency being 3.8 (N1), 8.4 (N2), 12.2 (N3) and 21.9 (N4) ms respectively. N1 showed wide distribution over the scalp and was considered to be of subcortical origin. N2-N4 were distributed in both the temporal and central area. The different distribution pattern of N2-N4 from conventional somatosensory-evoked potential suggested a different projection of LST from the medial lemniscus system.

CT-guided stereotactic surgery for evacuation of hypertensive intracerebral hematoma

During the last 3 years, 46 cases of hypertensive intracerebral hemorrhage were treated by CT-guided stereotactic surgery. Our present report is concerned with the evaluation of this procedure in the treatment of hypertensive intracerebral hematoma, in terms of the rate of aspirated hematoma and follow-up study of patients. It is difficult to draw any definite conclusion about the operative indications. CT-guided stereotactic aspiration, however, can be evaluated as a less invasive and more definitive treatment of intracerebral hematoma in the basal ganglia and thalamus.

[The incidence of postoperative epilepsy and prophylactic anticonvulsants in patients with intracranial aneurysm]

The occurrence of epileptic seizures is not rare after craniotomy. The authors examined the incidence of postoperative epilepsy in 150 patients of intracranial aneurysm. Anticonvulsants were given to all patients after operation, but in 12 cases anticonvulsants were discontinued because of liver dysfunction. One hundred and eight out of 138 cases (78%) were prescribed polypharmaceutically, and 30 of 138 cases (22%) were monopharmaceutically. The daily dose of anticonvulsants was as follows; diphenylhydantoin (DPH) was 150-300 mg, phenobarbital (PB) was 50-100 mg, valproic acid (VPA) was 600-1200 mg, and carbamazepin (CBZ) was 200-600 mg. Postoperative epilepsy occurred in 14 of 150 cases (9.3%); 13 cases with anticonvulsants, and 1 case without anticonvulsants. The site of aneurysm was as follows; 6 cases (10.3%) of AC aneurysm, 3 cases (9.7%) of MC aneurysm, 1 case (2.4%) of IC aneurysm, and 4 cases (21.1%) of multiple aneurysm. The interval between operation and epileptic seizure was ranged 2 to 57 months (mean 19.8 months); in 7 cases (50%) within 1 year, and in 13 cases (93%) within 3 years. The authors emphasize that prophylactic use of anticonvulsants is effective to control subclinical epileptic seizures, prescribing anticonvulsants to all patients after craniotomy in general. The medication of anticonvulsants for 3 years would be necessary for avoiding postoperative epileptic seizure.

[Stereotactic metrizamide cervical myelography]

A new apparatus is made for metrizamide cervical myelography. One part of the apparatus is a frame for immobilizing the head and the other is an assembly for guiding spinal needle insertion by lateral puncture. The head frame is made of concave plastic and three rubber discs for immobilizing the forehead and bilateral temporal region. The second piece of apparatus for guiding spinal needle insertion is movable in three directions: up and down, right and left and forward and backward. The sterilized guide made of acrylic is attached. The spinal needle is inserted along the groove of this sterilized guide. The apparatus makes it possible to locate the insertion point easily for the metrizamide cervical myelography by lateral C1-C2 puncture method in prone position, since the location of the tip of the inserted needle can be determined by the aid of lateral cervical x-ray and 10 mm scale, even if image intensifier of TV display screen is not available.

Somatotopic arrangement of lateral spinothalamic tract in percutaneous cervical cordotomy

As a new clinical approach for the purpose of mapping a lamina analysis, the present report deals with another landmark for insertion of the spinal needle in man other than the usual dentate ligament when performing a percutaneous cordotomy. Electrophysiological studies were made on 19 patients in order to determine the effect of electrostimulation with a bipolar concentric electrode, as well as to corroborate the position of the electrode radiologically. A new apparatus has been devised so that one can locate the target insertion point easily.

[Anatomical identification of horizontal sections on computed tomogram utilizing Schaltenbrand and Bailey's atlas of the human brain (author's transl)]

Difference in angles between horizontal section of Schaltenbrand & Bailey's atlas and horizontal section of CT based on Cantho-Meatal line is only 3.5 to 5.5 degrees. Therefore, the horizontal section of Schaltenbrand & Bailey's atlas can be utilized for analysis of the horizontal section of CT scan, because the basal ganglia are located approximately in the center of the cranial cavity. The lesions at the basal ganglia with superimposing technique utilizing the relation between horizontal section of Schaltenbrand & Bailey's atlas and analogue view of CT can be identified anatomically.

Alterations of immunoreactive beta-endorphin in the third ventricular fluid in response to electrical stimulation of the human periaqueductal gray matter

Immunoreactive beta-endorphin in the third ventricular fluid was measured in response to electrical stimulation of the periaqueductal gray matter in 8 patients with intractable pain during rostral mesencephalic reticulotomy for pain relief. In all patients, marked increase of immunoreactive beta-endorphin was observed. On the other hand, in cases of electrical stimulation of the zona incerta performed during stereoencephalotomy, in 5 patients with involuntary movement, immunoreactive beta-endorphin in the third ventricular fluid did not show any significant change. The authors conclude that the increase of immunoreactive beta-endorphin on electrical stimulation of the periaqueductal gray matter is not a nonspecific response to brain stimulation but a specific response in regard to cerebral localization of endorphins. Direct correlation between pain relief and periaqueductal gray stimulation is also questioned.

[Effect of cardiocrome on EEG arousal response (author's transl)]

The experiment was made on effect of Cardiocrome (containing Cytochrome c, Co-Carboxylase and Flavin mononucleotide), Cytochrome c and Cytidine diphosphate (CDP) choline on the EEG arousal response induced by electrical stimulation of mesencephalic reticular formation in 68 unanesthetized immobilized cats. The arousal response was accelerated by intravenous injection of Cardiocrome, Cytochrome c and CDP-choline. The accelerating effect of Cardiocrome was more prominet than that of Cytochrome c. In conclusion, it can be drawn that Cardiocrome has an arousal effect on consciousness.