Periventricular white matter lucency and cerebral blood flow autoregulation in hypertensive patients

The goal of this study was to elucidate the association between the development of periventricular white matter lucency and autoregulation of cerebral blood flow in hypertensive patients through the arteriovenous oxygen saturation difference method. We studied 51 hypertensive patients who had previously suffered from minor strokes (lacunar infarction, 43; deep basal minor hemorrhage, 8). Patients were divided into three groups based on the findings of periventricular white matter lucency. We measured the absolute value of resting cerebral blood flow using the argon inhalation method, and stepwise reduction of blood pressure was obtained with patients on a tilting table. Intracerebral venous blood sampling was accomplished by direct cannulation into the jugular vein up to the jugular bulb. We calculated several cerebral circulatory parameters, such as cerebrovascular resistance and cerebral oxygen consumption, and also delineated individual autoregulation curves. Cerebrovascular resistance was significantly greater in patients with severe periventricular white matter lucency than in patients without it (P < .05). Impaired autoregulation was also significantly more prevalent in patients with more severe periventricular lesions (P < .05). Multiple regression analysis revealed that the impaired autoregulation was significant and an independent determinant of the severity of such periventricular lesions (R = .34, P < .05). In conclusion, our findings indicated that hypertensive patients with severe periventricular white matter lucency were more likely to have impaired autoregulation of cerebral blood flow and suggest that stricter blood pressure control is required in such patients to prevent deterioration of the cerebral microcirculation.

Significance of VLA-4 and LFA-1 expressions in neoplastic follicle formation and its deterioration in B-cell non-Hodgkin's lymphomas

In an attempt to determine the roles of adhesion molecules in the formation and deterioration of neoplastic follicles, we used flow cytometry to investigate how strongly neoplastic B-cells express VLA-4 alpha and LFA-1 alpha on their surfaces. Neoplastic and normal B-cells were taken from 24 patients with B-cell non-Hodgkin's lymphomas (B-NHL) and 6 with B-cell chronic lymphocytic leukemia (B-CLL). The expression intensities of the adhesion molecules were graded as follows: (-), (+), (+2) and (+3). Normal B-cells expressed those molecules with an intensity of (+2). The data for VLA-4 alpha expression were as follows: follicular B-NHL [10/11; (+2) and 1/11; (+)], partially follicular [5/5; (+)], diffuse [8/8; (+)] and B-CLL [6/6; (-)]. Those for LFA-1 alpha were as follows: follicular B-NHL [7/11; (+2), 4/11; (+)], partially follicular [3/5; (+2), 2/5; (+)], diffuse [3/8; (+2), 5/8; (+)] and B-CLL [3/6; (+), 3/6; (-)]. These results suggest that VLA-4 molecules expressed on neoplastic B-cells may be involved closely in the formation and deterioration of neoplastic follicles, although the expression of LFA-1 molecules seems to play only a minor part in such events.

Effects of dihydropyridines on cerebral blood vessels

AIM

To evaluate the effects of dihydropyridine calcium antagonists on the cerebral circulation in stroke patients. DESIGN OF STUDIES: Mean cerebral circulation parameters were studied in chronic stroke patients with hypertension and treated acutely or chronically (2 weeks) with nicardipine or nifedipine retard. The effects of nicardipine on local cerebral blood flow were also studied in patients with a subacute brain infarction.

RESULTS

Mean cerebral blood flow was significantly increased after a single oral administration of nicardipine but not after nifedipine retard. Both calcium antagonists reduced mean arterial pressure. Nifedipine retard acted mainly by reducing blood pressure and nicardipine mainly by reducing cerebrovascular resistance.

CONCLUSION

Dihydropyridines have a beneficial effect in the control of hypertension in stroke patients.

Accelerated brain infarction in hypertension complicated by hereditary heterozygous protein C deficiency

BACKGROUND

Protein C deficiency leads to reduced inhibition of coagulation and an increased likelihood of thrombosis. It is widely accepted that the most common syndromes associated with protein C deficiency are venous thrombosis and pulmonary thromboembolism, whereas arterial thrombosis is rare. Here we describe two patients with hypertension and hereditary heterozygous protein C deficiency who developed multiple lacunar infarcts.

CASE DESCRIPTIONS

Patient 1 was a 46-year-old man with a history of hypertension who developed a right upper quadrantanopia and gradually progressive intellectual and behavioral deterioration. Patient 2 was a 61-year-old man with history of hypertension and two episodes of right-sided motor weakness who developed left sixth and seventh cranial-nerve palsies and reduced pinprick sensation in the right extremities. In both patients, magnetic resonance imaging revealed multiple small lesions in the pons as well as the bilateral basal ganglia, thalamus, corona radiata, and other subcortical structures, which are consistent with lacunar infarcts. Protein C activity and antigen levels were reduced to approximately one half of normal in these two patients, as well as in some of their family members who had no other serological or coagulation abnormalities. A diagnosis of heterozygous protein C deficiency type 1 was thus established.

CONCLUSIONS

Although it remains uncertain whether protein C deficiency itself increases the risk of cerebral artery thrombosis, it may predispose a patient to develop multiple brain infarctions in association with hypertension.

Clinical implication and prognostic significance of small lymphoma cells in the peripheral blood and bone marrow of B-cell non-Hodgkin's lymphomas

It seems possible that small lymphoma cells (SLC) may have a role even in aggressive B-cell non-Hodgkin's lymphoma (B-NHL) such as large-cell lymphoma. However, SLC are often difficult to distinguish morphologically from normal or reactive small lymphocytes. In this study, we used a flowcytometric technique (kappa-lambda imaging; KLI) for detection of SLC. Peripheral blood (PB) and bone marrow (BM) samples taken from 41 patients with surface immunoglobulin positive (sIg+) B-NHL were analysed. SLC were detected in about 90% (37/41) of the untreated patients when either PB or BM was analysed by KLI. The presence of SLC correlated well with disease activity. However, a few SLC were present even in the PB (16%) or BM (27%) of the 31 patients who achieved complete remission, indicating that minimal residual disease (MRD) was present. In some cases, the reappearance of SLC in the PB or BM preceded clinical relapse. Furthermore, the initial volume of SLC, particularly in the BM, tended to be related to the prognosis (P = .068). These results suggest that the detection of SLC by KLI may be helpful not only for the screening and clinical staging of sIg+ B-NHL, but also for monitoring disease activity and detecting MRD. Moreover, the volume of SLC in the BM may be a useful predictor of prognosis.

[A case of Evans' syndrome in which CD4+CD45RA+ cells markedly decreased in its active phase]

A 38-year-old man was admitted to our hospital because of exertional dyspnea in February, 1990. The patient had already been diagnosed as having autoimmune hemolytic anemia (AIHA) in February, 1982 and treated with prednisolone (PSL) until January, 1988. The laboratory examination confirmed the relapse of AIHA (IgG-warm type) and additionally disclosed the marked decrease of CD4+CD45RA+/CD4+ ratio in peripheral blood lymphocytes. Thereupon, the patient was treated again with PSL and entered the remission in one month. Simultaneously, CD4+CD45RA+/CD4+ ratio also increased to the normal level. Afterwards, the remission had been maintained for about six months with a small dose of PSL. However, in September, 1990, the hemolysis relapsed with marked thrombocytopenia and decreased CD4+CD45RA+ ratio. Then the diagnosis was corrected to Evans' syndrome because PAIgG was highly elevated together with positive Coombs' test. Although danazol and azathioprine were administered in addition to PSL, the disease remained in active phase. Thus, splenectomy was carried out in March, 1992. Consequently, the patient entered the remission that has been maintained over six months. CD4+CD45RA+/CD4+ ratio was also normalized. These results suggest that CD4+CD45RA+ cells may play an important role in the pathogenesis of AIHA or Evans' syndrome.

Acute myeloid leukemia with concomitant expression of T-/B-lymphoid antigens and immunogenotypic alterations exhibiting t(7;12)(q32;q24)

We report here a patient with acute myeloid leukemia (AML) expressing both T- and B-lymphoid-associated antigens. The leukemia cells in this case had rearrangements of not only immunoglobulin heavy-chain but also T-cell-receptor beta- and delta-chain genes. Although a relatively large number of AML patients with lymphoid markers have been reported, only about a dozen AML patients expressing both T- and B-lymphoid markers have been reported so far.

[A two-dimensional analysis of B-lymphoma cells by flow cytometry--a comparative study with pathological classification]

In order to investigate the size variation of neoplastic cells from lymph nodes of 19 patients with B-cell non-Hodgkin's lymphomas (B-NHL), we have carried out the two-dimensional analysis by flow cytometry using the parameters of the forward light scatter (FLS) and the fluorescence intensity of surface immunoglobulin light chain (sIgL). Neoplastic B cells were identified as having the homogeneous characters of both FLS and sIgL (kappa or lambda) in comparison of normal B cells with the heterogeneity of counterpart sIgL (lambda or kappa). Then the size variation of neoplastic B cells was analyzed by regarding CD3+ T cells to a control scale. Consequently, the present procedures disclosed that B-NHL cases could be divided into five patterns from the view-point of the cell size and distribution. These results almost coincided with the cell types determined by the pathological diagnosis. Furthermore, it was also found that our data made it possible to classify small cleaved cell or large cell lymphomas into subtypes. The two-dimensional analysis by using the parameters of FLS and sIgL would be clinically useful for the rapid diagnosis of B-NHL and its malignant grade in addition to supporting pathological findings.

Angiographic evaluation of brain infarction limited to the anterior cerebral artery territory

BACKGROUND AND PURPOSE

Brain infarction localized in the anterior cerebral artery territory is rather uncommon, and its etiology has not yet been fully elucidated.

METHODS

Based on computed tomographic findings, 17 patients with solitary anterior cerebral artery territory infarction were selected from among 3,619 patients admitted consecutively to our institute. Patients without angiographic examinations were excluded. The angiographic findings and clinical category of stroke were analyzed in each patient.

RESULTS

Angiographic abnormalities were revealed in all patients. These consisted of occlusive changes (n = 10) or reversible segmental dilatation (n = 3) of the anterior cerebral artery, A1 hypoplasia (n = 5), and occlusive changes of the carotid artery (n = 3). In one patient with anterior cerebral artery occlusion, the occluded artery was reopened and subsequently became reoccluded. The clinical category of stroke was classified as atherothrombotic in 10 patients, cardioembolic in three, and undetermined in the remaining four. In eight of the 10 patients with atherothrombotic infarction, the anterior cerebral artery was narrowed or occluded. In all patients with cardioembolic infarction, the A1 segment contralateral to the infarction was hypoplastic.

CONCLUSIONS

In our series, solitary anterior cerebral artery territory infarction was attributable most commonly to local atherothrombosis and occasionally to cardiogenic embolism. A hypoplastic A1 segment may facilitate the occurrence of embolism in the anterior cerebral artery. Reversible dilatatory and occlusive changes of this artery may be another important cause of infarction.

Hemorrhagic and ischemic cerebrovascular complications of active infective endocarditis of native valve

Cerebrovascular events complicate the management of infective endocarditis. The purpose of this study is to analyze clinical features of cerebrovascular complications in infective endocarditis and to establish the appropriate time schedule of chemotherapy and cardiosurgical intervention. We studied the clinical data of 123 patients with active infective endocarditis of native valves retrospectively. Thirty-three patients (18 males and 15 females, age 17-57 years) had cerebrovascular complications such as cerebral ischemia (n = 22) or intracranial hemorrhage (n = 11). The majority of complications (21 ischemic and 13 hemorrhagic episodes) occurred prior to or within 1 month after chemotherapy. Fatal neurological deterioration developed after cardiac surgery in 2 patients. Both of them needed emergency cardiac surgery, because of worsening hemodynamic state, which was performed within 5 days after cerebral embolic events. The remaining patients undertaking cardiac surgery did all survive; in whom there were chemotherapeutic intervals of 11 days after ischemic events or of 23 days after hemorrhagic events. These medical records suggest that early cardiosurgical intervention, if necessary, needs at least 2-3 weeks of preceding chemotherapy. In cases undergoing more than 1 month of chemotherapy, cerebrovascular complications may be well managed by medical treatment alone.

Ataxic hemiparesis following thalamic lacunar infarction

A 60-year-old man developed left hemiparesis and homolateral ataxia with normal sensation and normal somatosensory evoked potentials. A lacunar infarct with gadolinium enhancement in the right dorsolateral part of the thalamus was demonstrated on magnetic resonance imaging. Thalamic lesion is a relatively rare cause of ataxic hemiparesis; most of the reported cases of ataxic hemiparesis caused by thalamic lesion were accompanied by sensory disturbances. This is an interesting case which suggested that the thalamic lesion could be responsible for the ataxic hemiparesis without a sensory disturbance.

Clinical and prognostic significance of monoclonal small cells in the peripheral blood and bone marrow of various B-cell lymphomas

Discordant lymphomas, in particular nodal large-cell lymphomas with marrow small-cell lymphoma, were discovered recently, and the prognosis of patients with such disease has been discussed. The small cells were reported to be small lymphocytic or small cleaved lymphoma cells. We have detected, by kappa-lambda imaging (KLI) with delta-curves, using a flow cytometer, small lymphoma cells in the peripheral blood (PB) and bone marrow (BM) of 41 untreated patients with various B-cell lymphomas expressing surface Ig (sIg+BCL), and evaluated their clinical and prognostic significance. Small cells were found in approximately 90% (37 of 41) of sIg+BCL patients when either PB or BM was analyzed and, overall, the presence of small cells correlated well with the disease activity. However, in some patients, a few cells remained in the PB (16%) or BM (27%) even when they were in remission, whereas in others, the cells were presented in the PB or BM several months before relapse. These results suggest that the detection of small cells in PB or BM by KLI may be helpful for screening and monitoring patients with sIg+BCL. When the patients were subdivided into three groups (normal, low, and high amplitude), according to the abnormal grade criteria of the delta-curves, which were based on the results of both PB-KLI and BM-KLI, the survival of the high-amplitude group tended to be shorter than that of the normal group (P = .068), which was particularly marked when the follow-up period exceeded 2 years. Moreover, as the group grading worsened (normal less than low less than high), the complete response rates deteriorated (100%, 71%, and 60%, respectively) and the respective relapse rates after complete remission increased (17%, 40%, and 67%). Thus, the determination of the proportion of small lymphoma cells in PB and BM by KLI may be useful for predicting the prognoses of patients with sIg+BCL.

Histopathological analysis of the mechanisms of intracranial hemorrhage complicating infective endocarditis

BACKGROUND AND PURPOSE

We conducted the present study to elucidate the pathological mechanisms leading to intracranial hemorrhage complicating infective endocarditis.

METHODS

Neurological, neuroradiological, and histopathological analyses were performed in 16 patients (one surgical and 15 autopsy cases), 12 men and four women 26-68 years of age, who had demonstrated central nervous system complications during the course of infective endocarditis.

RESULTS

Intracranial hemorrhage was found in all cases; parenchymal hematomas were found in 12 cases, hemorrhagic infarcts in four cases, and primary subarachnoid hemorrhages in two cases. Chronological analysis of neurological examination and computed tomographic scan of the brain confirmed that antecedent cerebral ischemic events had occurred in five of 12 patients showing parenchymal hematomas at autopsy. Hemorrhagic infarct, indicated by petechial or diffuse hemorrhages within the infarct, was seen in another four patients, so that hemorrhagic transformation of the ischemic infarct was confirmed in nine patients. Although mycotic aneurysms were found in five patients, only three of these were ruptured; the other two were occluded with septic emboli. Pyogenic arteritis without aneurysm was found to be distributed in the small cortical arterial branches located in the spaces of cortical sulci, with rupture occurring in five patients.

CONCLUSIONS

These results suggest that hemorrhagic transformation of the ischemic infarct due to septic emboli is the most frequent mechanism leading to intracerebral hemorrhage encountered in patients dying of infective endocarditis and that rupture of pyogenic arteritis may be responsible for such hemorrhage in many cases, with ruptures of mycotic aneurysms as an alternative mechanism.

Sequential changes of sodium magnetic resonance images after cerebral hemorrhage

Four patients with cerebral hemorrhage were examined serially from the acute to chronic phase by 1H magnetic resonance imaging (MRI), 23Na MRI and computed tomography (CT). At 1-2 days after bleeding, the 23Na image revealed no visible signal change in the area of hemorrhage, although CT and 1H images clearly demonstrated the existence of a hematoma in the thalamus or putamen. At 4-7 days after the hemorrhage, the 23Na images began to exhibit a small increase in signal intensity at the hematoma site, while at 2-3 weeks, a marked increase in 23Na signal intensity was observed. These findings suggest that the hematoma consisted mainly of a corpuscular component, with a low Na+ concentration, with little serum component. Lack of signal from the corpuscular component on the 23Na image was confirmed by an in vitro study. In the late acute phase, Na+ accumulation may occur in the corpuscular component due to failure of the Na+ pump. The intracellular 23Na appears to be totally visible to MRI, resulting in an increase in signal intensity. In the subacute or chronic phase, the corpuscular component may be destroyed, leaving fluid in its place. A high Na+ concentration in this fluid may give markedly increased 23Na signal intensity on MRI. 23Na MRI appears to provide important information for understanding the evolution of cerebral hemorrhage and for estimating the viability of cells, although its value for diagnosis may not be great.

[Surgical decisions for active infective endocarditis in patients with acute neurological complications]

The surgical management of 7 patients with active infective endocarditis and recent (within 16 days) neurological injury was presented. All patients had preoperative computed tomographic scans which revealed no evidence of intracranial hemorrhage and underwent successful corrective cardiac surgery. In the early postoperative period, 4 patients died of cerebral hemorrhage, subarachnoid hemorrhage, or progression of cerebral edema. Two of the 3 surviving patients showed no aggravation of cerebral infarcts postoperatively. In the remaining surviving patient, intracerebral mycotic aneurysms were resolved spontaneously after postoperative antibiotic therapy, although new cerebral hemorrhage, a complication of emboli, occurred after open heart surgery. The results of this study indicated that 1) cerebrovascular complications were the causes of the 4 deaths in this series, and 2) although heparinization during open heart surgery may result in intracerebral hemorrhage from mycotic aneurysm or infarction, early surgical intervention after recent cardiogenic embolic strokes may save patients with minor cerebral infarcts.

Cerebral infarction associated with protein C deficiency

BACKGROUND AND PURPOSE

A deficiency of plasma protein C, both the hereditary and acquired types, is one cause of thromboembolic disease. Several antineoplastic agents have been reported to decrease the production of protein C in the liver by impairing either the absorption or metabolism of vitamin K, leading to acquired protein C deficiency.

CASE DESCRIPTION

We treated a young woman with protein C deficiency, who had developed a cerebral infarction of the right parietal cortex of sudden onset. On admission, the antigenic level of plasma protein C was 38%. Serial cerebral angiography revealed occlusion of the right middle cerebral artery, which subsequently recanalized completely. This patient had taken fluorouracil derivatives orally for as long as 3 years following a left mastectomy for stage II breast cancer. Tests revealed that the patient's mother had only one-half the normal activity of plasma protein C despite a normal antigenic level.

CONCLUSIONS

We speculate that the etiology of the cerebral infarction in this patient might involve an embolic mechanism associated with protein C deficiency induced by an interaction between inherited and acquired factors.

Age variation in the upper limit of hearing and amplitude of eye accommodation in childhood and adolescence

The upper limit of hearing and amplitude of eye accommodation were examined, and their standard aging curves were established in order to evaluate their age-related changes in childhood and adolescence. The subjects were 2497 audiometrically and otologically normal ears and 2349 optometrically and ophthalmologically normal eyes ranging in age from 5 to 24 years in Japan. The upper limit of hearing was measured by the equipment made by us. The amplitude of eye accommodation was calculated at near point and far point measured by the ophthalmodynamometer. Both the upper limit of hearing and amplitude of eye accommodation became gradually less as age increased. The variability of the upper limit of hearing was less than that of the amplitude of eye accommodation. Standard aging curves were established in childhood and adolescence by calculating 10th, 25th, 50th, 75th and 90th centiles. There is no significant relationship between the upper limit of hearing and the amplitude of eye accommodation.

[Targeting anticancer chemotherapy dispersed in lipid contrast medium in hepatoblastoma in childhood]

Fourteen cases of malignant liver tumor in childhood were experienced in our department during past 14 years. Since 1984 we have performed preoperative targeting anticancer chemotherapy using oily anticancer agents such as THP-adriamycin 30 mg/m2. These oil emulsion was making with 20 mg amounts of THP-adriamycin dissolved in 5 ml urographin and 15 ml volume of lipiodol. These mixture were administered by catheterizing the hepatic artery under X-ray monitoring in 6 cases with hepatoblastoma. Remarkable anticancer effects of this targeting chemotherapy were achieved, the serum AFP level and tumor size both showing a decrease in all cases, and the resectability of tumor showing a increase in 5 among 6 cases in comparison with 50% resectability before 1983.

Brain damage after open heart surgery in patients with acute cardioembolic stroke

We evaluated 14 patients with acute cardiogenic embolism who underwent open heart surgery soon after the onset to determine the cerebral and cardiac factors that influence neurologic outcome. The mean interval from onset of cerebral embolism to surgery was 5.3 (range 1-16) days. Five of the 14 patients had vegetations from infective endocarditis (including prosthetic valve endocarditis) as embolic sources, eight had intracardiac thrombi, and one had atrial myxoma. The diagnosed site of infarction before surgery was based on computed tomographic and/or angiographic findings. Of the 14 patients, four had infarcts due to major artery occlusion, seven due to cortical branch occlusion, and two due to perforating artery occlusion; one patient presented with a transient ischemic attack without computed tomographic abnormalities. Ten patients (71%) showed no clinical aggravation after open heart surgery; however, two patients died of massive cerebral hemorrhage, one died of deterioration of brain edema, and another became comatose from midbrain hemorrhage immediately after surgery. The four patients with clinical aggravation comprised three with septic embolism and one with aseptic occlusion of a major artery. From these results, infective endocarditis and a large infarct appear to be possible aggravating factors when patients with recent cerebral embolism undergo open heart surgery.

Estimation of vertebral arterial asymmetry by computed tomography

In 80 patients with no stenotic lesions in the vertebrobasilar arterial system, a study was made of the relationship between the deviation of the basilar artery (BA) from the midline on computed tomography (CT) and the right-to-left vertebral arterial caliber difference on angiograms. In 66 patients (83%), the BA was visible on plain CT films, and 55 of them showed deviation of the BA to either side. In 44 of these patients (80%), the vertebral artery (VA) contralateral to the side of BA deviation had a larger caliber compared with the ipsilateral one on angiograms. In 6 patients whose unilateral VA terminated in the posterior inferior cerebellar artery (PICA) and showed an extremely small caliber compared to the contralateral one, the BA was always deviated to the side of the smaller VA. Our data suggest that the deviation of the BA on plain CT films may represent a good indicator for estimating the right-to-left VA caliber difference. At the time of vertebral angiography, injection of contrast medium should preferably be made from the larger VA in order to avoid laminar flow in the BA and to shorten the procedure. Prior estimation of the right-to-left VA caliber difference by CT may be of great benefit to the angiographic procedure.

Positive platelet scintigram of a vertebral aneurysm presenting thromboembolic transient ischemic attacks

We describe a patient with transient ischemic attacks secondary to a giant aneurysm who showed increased activity on platelet scintigrams at the origin of the left vertebral artery. This is assumed to be the first report of a presumed embolizing aneurysm with positive activity of labeled platelets. Platelet scintigraphy is useful for diagnosing transient ischemic attacks as being secondary to an aneurysm and was proved to provide direct evidence of a thromboembolic source in vivo.

Comparison of dynamic and xenon computed tomography in the evaluation of cerebrovascular ischemia

Dynamic computed tomographic (DCT) scans with iodine contrast enhancement were compared with simultaneously obtained xenon CT studies of cerebral blood flow (CBF) in 15 patients with subacute or chronic cerebrovascular ischemic disease. Specifically, the width and corrected first moment (cMT1), as demonstrated by DCT, were compared with the regional CBF (rCBF) data and the rCBF map obtained with xenon CT. The DCT and rCBF images were well correlated in patients without, but poorly correlated in those with, leptomeningeal anastomotic collateral circulation. The correlation of rCBF and 1/width with 1/cMT1 was significant (r = 0.78, p less than 0.01) in the former, but not in the latter. These data were thought to reflect a difference in the tracer inflow pattern between the patients with and those without leptomeningeal anastomoses. Our series did not include patients with acute cerebral infarction or recanalization, which are thought to be associated with marked changes in cerebral blood volume in the affected region. However, the influence of cerebral blood volume should be studied in detail in our subacute or chronic series.

[Delayed primary operation of solid tumors in children]

Delayed primary operation has been started since 1982 in our department and 19 cases of solid tumor in childhood were treated with this method. They included 11 cases of advanced neuroblastoma, 5 cases of hepatoblastoma and 3 cases of yolk sac tumor in sacrococcygeal area. We discussed effectiveness of preoperative chemotherapy to the primary tumor and metastatic lesions, the best timing of operation after chemotherapy and the operative technique in delayed primary operation. Preoperative chemotherapy were useful in almost all cases of delayed primary operation, so the primary lesion and lymph nodes metastases were removed easily. We recommended it was the best timing of operation when 2 or 3 courses of preoperative chemotherapy were finished. CUSA (Cavitron Ultrasonic Surgical Aspirator) was the useful instrument to remove the primary tumor and lymph node metastases completely in advanced neuroblastoma preserving both kidneys.