Radiosurgery of cavernous hemangiomas in the cavernous sinus

BACKGROUND

Cavernous hemangiomas in the cavernous sinus are rare and demonstrate unique clinical courses. Although they rarely cause spontaneous bleeding, serious bleeding is not uncommon during operations. Total eradication of such tumors is very difficult because of the location and intraoperative bleeding. Consequently, alternatives to operative resection have been examined.

METHODS

Three cases of cavernous hemangiomas in the cavernous sinus, presenting chiefly with ocular signs and facial pain, were treated by radiosurgery using a gamma knife. Two of the patients had been operated on before radiosurgery, while the third patient was diagnosed on the basis of neurological signs as well as radiological findings.

RESULTS

MRI scans at the time of radiosurgery showed tumors in the cavernous sinus with low or iso-intensity on T1-weighted images and high signal intensity on T2-weighted images. All of the tumors intensely enhanced with gadolinium-DTPA. The tumors had diameters of 14 to 28 mm and were treated with a marginal dose of 14 to 17 Gy (mean 15.7 Gy). In the mean follow-up period of 27 months after radiosurgery, all of the tumors decreased in size (PR). Neurologically, none of the patients showed any deterioration, and one demonstrated an obvious improvement in ocular movement.

CONCLUSIONS

Radiosurgery for cavernous hemangioma in the cavernous sinus is apparently safe and effective with consistent tumor shrinkage. Therefore, radiosurgery is an excellent alternative to operative intervention and may even replace operative procedures if the tumors are small in diameter or when they recur.

Correlation between neuroimaging and neurological outcome in periventricular leukomalacia: diagnostic criteria

BACKGROUND

Periventricular leukomalacia (PVL) is the most important factor in cerebral palsy in preterm infants.

METHODS

In the present study, we investigated 747 preterm infants of less than 36 weeks gestation who were repeatedly examined by cranial ultrasonography and computed tomography (CT) scanning at around 40 weeks of corrected post-menstrual age. The clinical course of these infants was followed for more than 3 years and they were examined by magnetic resonance imaging (MRI) between 12 and 18 months of age.

RESULTS

Single examinations in early infancy were not sufficient to diagnose PVL, but the combination of ultrasonography, CT and MRI examinations allowed the clinical diagnosis of PVL. In preterm infants, clinical PVL could be predicted from cystic PVL and periventricular echogenicity (PVE) 3 or PVE 2 prolonged over 3 weeks on ultrasonography and confirmed by MRI after 11 months of corrected age.

CONCLUSIONS

We tried to determine diagnostic criteria for PVL by neuroimaging. Such criteria from neuroimaging for PVL may be useful for determining the exact occurrence rate of and clinical risk factors for PVL.

Long-term results of stereotactic gamma radiosurgery of meningiomas

BACKGROUND

The early effects at a mean of 30 months and long-term results at 7 years after gamma radiosurgery for meningiomas were evaluated.

METHODS

Changes in tumor size were evaluated every 3 to 6 months after treatment using a five-point grading system, as well as changes in neurological signs and general status.

RESULTS

Early effects in 87 cases of benign meningioma showed a minimal size reduction of 16.1% and a response rate of 8.0%, but a higher control rate of 93%. The cavernous sinus meningioma showed a size reduction of 23.2%, a response rate of 11.1%, and control of 100%. A greater size reduction of 24.8% and response rate of 33.3%, but a lower control rate of 75% were obtained in 12 cases of malignant meningioma. Side effects were found in 12 cases (13.8%): radiation-induced edema in 9, hearing disturbance in 2, and visual deterioration in 1. Long-term results for 54 of 87 patients with benign tumors showed that response increased from 8% to 42.6% but control decreased slightly due to increased disease progression.

CONCLUSION

Gamma radiosurgery is effective and safe for meningiomas to control residual or recurrent tumors after surgery and initial tumors, with acceptable side effects and rate of tumor progression.

Embolization of cerebral arteriovenous malformations to enhance the success of subsequent radiosurgery

SUMMARY

We studied angiographic changes in embolized arteriovenous malformations (AVMs) by comparing pre- and postembolization angiograms and angiograms preceding radiosurgery. This study sought factors determining the usefulness of embolization as a pretreatment to enhance the success of subsequent radiosurgery. Thirty patients with cerebral AVMs treated in this manner over 4 years were studied. In these cases AVMs were embolized with cyanoacrylate and were treated with Gamma-knife radiosurgery. The mean size of the AVM nidus was reduced by a fraction of seven following embolization. The subsequent angiogram for planning radiosurgery showed further nidus reduction in 10 AVMs, no change in 12, and regrowth in 8. In all size-reduction cases the nidus was sufficiently packed, and 2 AVMs had thrombosed completely before radiosurgery. All the regrowing AVMs were of diffuse type; 6 were associated with already-developed leptomeningeal channels, and the remaining 3 were fed by newly sprouted meningeal feeders. Five AVMs disappeared following radiosurgery, all representing size-reduction or nochange cases. Analysis of cases with regrowth showed increased risk of that event with feeder occlusion of a multi-axially supplied AVM, lack of reduction of shunt flow, or remaining meningeal feeders. On the other hand, when embolization as pretreatment prior to radiosurgery succeeds in producing a small, compacted, plexiform nidus with slow shunt flow, it furthers the likelihood of successful radiosurgery. Nidus embolization and occlusion of fistulous and meningeal feeders are mandatory, while proximal feeder occlusion and use of embolic materials which risk recanalization should be avoided to prevent nidus regrowth.

Localization of mouse CLC-6 and CLC-7 mRNA and their functional complementation of yeast CLC gene mutant

CLC-6 and CLC-7 belong to the family of voltage-dependent chloride channels. To learn more about the in vivo roles of CLC-6 and CLC-7, we performed in situ hybridization of these CLC channels in various mouse organs. Mouse CLC-6 (mCLC-6) was expressed in the peripheral region of seminiferous tubules in the testis, tracheal epithelium, epithelium of bronchioles, alveolar cells in the lung, acinar cells in the pancreas, and intestinal epithelium, but we could not detect signals from pancreatic islets. Mouse CLC-7 (mCLC-7) was expressed in neurons in the medulla oblongata, Purkinje cells in the cerebellum, proximal tubules in the kidney, and hepatocytes in the liver. The distribution of mCLC-6 and mCLC-7 were similar in the lung, pancreas, and testis. mCLC-6 functionally complemented the gef1 phenotype of a yeast strain in which a single CLC channel (GEF1) had been disrupted by homologous recombination. In contrast, mCLC-7 did not complement this gef1 phenotype. This study identified the cell types that express mCLC-6 and mCLC-7 in the mouse tissues, and the complementation assay suggested that mCLC-6 functions as an intracellular chloride channel.

Early immunohistochemical detection of axonal damage and glial activation in extremely immature brains with periventricular leukomalacia

Extremely low birth weight (ELBW) infants, who died at 12 hours to 7 days after birth, with periventricular leukomalacia (PVL), were examined by means of neuropathological and immunohistochemical methods. Fourteen infants without PVL were used as controls. Anti-beta-amyloid precursor protein (APP), glial fibrillary acidic protein (GFAP), and ionized calcium-binding adaptor molecule 1 (Iba1) antibodies were used as markers for axonal damage, reactive astrocytes and activated microglia, respectively. Thirteen of 14 ELBW infants with PVL showed a widespread distribution of leukomalacia and 10 showed postnatal-onset of leukomalacia. In 12 of the 14 infants with PVL, regions of APP-reactive axons were found multifocally in the cerebral white matter, but 8 of them did not show coagulation necrosis on HE staining. GFAP-positive cells and Iba1-positive cells were markedly found in the white matter of all cases with PVL and slightly in all 14 controls. These results indicated that in ELBW infants, the distribution and formation of PVL foci are widespread and characteristic and so may involve motor and intellectual abilities in ELBW infants. Therefore, the perinatal management to maintain an appropriate cerebral circulation and oxygenation may be very important.

Gamma knife radiosurgery for low-grade astrocytomas: results of long-term follow up

OBJECT

The purpose of this paper is to report the long-term results of gamma knife radiosurgery (GKS) for low-grade astrocytomas.

METHODS

Fifty-one patients with low-grade astrocytomas treated with GKS and followed for more than 24 months are reported. Of the 51 patients, 12 harbored Grade I astrocytomas in and around the visual pathways and hypothalamus. The remaining 39 harbored Grade II astrocytomas. The mean patient age at time of GKS was 9.8 years for patient with Grade I and 30.9 years for those with Grade II astrocytomas. The mean tumor diameter was 25.4 mm for Grade I and 23.7 mm for Grade II tumors. The mean margin dose was 12.5 Gy for Grade I and 15.7 Gy for Grade II tumors. In the mean follow-up period of 27.6 months, both Grade I and Grade II astrocytomas responded well to GKS. Grade I astrocytomas had a response rate of 50% and a control rate of 91.7%. Grade II astrocytomas had a 46.2% response rate and an 87.2% control rate. Statistical analyses concerning the efficacy and related factors showed a significantly better response for patients 10 years of age or older with Grade I and those with a follow-up period of more than 24 months. Complications included radiation-induced edema in 18 (35.3%) of 51 cases, cyst formation or enlargement in five (9.8%), and transient tumor enlargement in three (5.9%).

CONCLUSIONS

Radiosurgery can play an important role in the treatment of low-grade astrocytomas, and complete cure of these tumors is expected in at least some of the cases.

Radiosurgery for epilepsy associated with cavernous malformation: retrospective study in 49 patients

OBJECTIVE

Microsurgical resection of a cavernous malformation (CM) with or without associated cortical resection can provide efficient treatment of drug-resistant associated epilepsy. To explore the potential alternative role of radiosurgery and to evaluate its safety and efficacy for this indication, we conducted a retrospective multicenter study.

METHODS

We retrospectively reviewed the files of patients with long-lasting drug-resistant epilepsy, presumably caused by CM, who were treated by gamma knife (GK) surgery for the control of their epilepsy in five centers (Marseilles, Komaki City, Prague, Graz, and Sheffield). A satisfactory follow-up was available for 49 patients (mean follow-up period, 23.66 +/- 13 mo). The mean duration of epilepsy before the GK procedure was 7.5 (+/-9.3) years. The mean frequency of seizures was 6.9/month (+/-14). The mean marginal radiation dose was 19.17 Gy +/- 4.4 (range, 11.25-36). Among the 49 patients, 17 (35%) had a CM located in or involving a highly functional area.

RESULTS

At the last follow-up examination, 26 patients (53%) were seizure-free (Engel's Class I), including 24 in Class IA (49%) and 2 patients with occasional auras (Class IB, 4%). A highly significant decrease in the number of seizures was achieved in 10 patients (Class IIB, 20%). The remaining 13 patients (26%) showed little or no improvement. The mediotemporal site was associated with a higher risk of failure. One patient bled during the observation period, and another experienced radiation-induced edema with transient aphasia. Postradiosurgery excision was performed in five patients, and a second radiosurgical treatment was carried out in one patient.

CONCLUSION

This series is the first to specifically evaluate the capability of GK surgery to safely and efficiently treat epilepsy associated with CM. Seizure control can be reached when a good electroclinical correlation exists between CM location and epileptogenic zone. Although we do not recommend GK surgery for prevention of bleeding for a CM that has not bled previously, our findings suggest that GK surgery can be proposed for the treatment of epilepsy when the CM is located in a highly functional area.

Characterization of the signal that directs Tom20 to the mitochondrial outer membrane

Tom20 is a major receptor of the mitochondrial preprotein translocation system and is bound to the outer membrane through the NH(2)-terminal transmembrane domain (TMD) in an Nin-Ccyt orientation. We analyzed the mitochondria-targeting signal of rat Tom20 (rTom20) in COS-7 cells, using green fluorescent protein (GFP) as the reporter by systematically introducing deletions or mutations into the TMD or the flanking regions. Moderate TMD hydrophobicity and a net positive charge within five residues of the COOH-terminal flanking region were both critical for mitochondria targeting. Constructs without net positive charges within the flanking region, as well as those with high TMD hydrophobicity, were targeted to the ER-Golgi compartments. Intracellular localization of rTom20-GFP fusions, determined by fluorescence microscopy, was further verified by cell fractionation. The signal recognition particle (SRP)-induced translation arrest and photo-cross-linking demonstrated that SRP recognized the TMD of rTom20-GFP, but with reduced affinity, while the positive charge at the COOH-terminal flanking segment inhibited the translation arrest. The mitochondria-targeting signal identified in vivo also functioned in the in vitro system. We conclude that NH(2)-terminal TMD with a moderate hydrophobicity and a net positive charge in the COOH-terminal flanking region function as the mitochondria-targeting signal of the outer membrane proteins, evading SRP-dependent ER targeting.

Seizure control after radiosurgery on cerebral arteriovenous malformations

Among 462 cases of cerebral arteriovenous malformation (AVM) treated with gamma-radiosurgery, the initial presentations were haemorrhage in 68%, epilepsy in 12.8%, neurological deficits in 3.2%, minor symptoms in 7.6% and asymptomatic in 4.5% respectively. There were 79 cases (17.1%) who had had a convulsive seizure before radiosurgery and they were classified into two groups: 58 cases presented with seizure as an initial symptoms (group A) and the other 21 cases mostly had seizures following intracranial haemorrhage (group B). Before radiosurgery, generalised seizure was the predominant seizure pattern in both groups, followed by pure partial and complex partial seizures. There was no major difference in seizure patterns or seizure frequency in group A and B. At radiosurgery AVMs were treated with a mean maximum dose of 37.2 Gy and a marginal dose of 19.8 Gy. Seizures had apparently decreased in most of the cases at the last follow-up (mean 24 months) according to the obliteration of the nidus. Seizures were either decreased or had disappeared in 91.6% of group A and 62.5% of group B patients. The overall results indicate that seizures improved in 85.5%, were changed in 11.6% and deteriorated in 2.9% of patients. Radiosurgery is effective not only for the obliteration of nidus of cerebral AVM, but also for seizure control, even before complete occlusion of the nidus.

Embolisation of cerebral arteriovenous malformations to assure successful subsequent radiosurgery

This study investigated the angiographic changes in embolised arteriovenous malformations (AVMs) pre- and post-embolisation and preradiosurgery to clarify the usefulness of embolisation as a pretreatment for radiosurgery and the strategy of embolisation for the radiosurgical success. A total of 37 patients with cerebral AVMs treated over a period of 4 years was investigated. All the AVMs were embolised with N-butyl cyanoacrylate and 2 months later they were treated by radiosurgery. The size of AVM nidus reduced just following the embolisation (mean 21.9 ml to 3.9 ml). The angiogram taken in preparation for radiosurgery showed a further size reduction in the nidus of 16 AVMs, no change in 10 and regrowth in 11. In all the cases where size was reduced, the nidus was densely packed, while all the regrown AVMs were of the diffuse type. Five AVMs disappeared following radiosurgery, all of which were size-reduction or no-change cases. In conclusion, to achieve success in subsequent radiosurgery, nidus embolisation and the occlusion of fistulous and meningeal feeders are mandatory. Imprudent proximal feeder occlusion and the use of embolic materials with a risk of recanalisation should be avoided to prevent regrowth of the nidus, which may lead to errors in planning the radiosurgery to follow.

A case of atypical chronic myeloid leukemia regarded as MDS with myeloproliferative features

We report a case of atypical chronic myeloid leukemia (aCML) who showed marked neutrophilia without dysplastic features, basophilia or monocytosis. These findings diverged somewhat from the FAB criteria for aCML. The patient's erythroid cells and megakaryocytes were dysplastic. His marrow cells formed no spontaneous colonies, as shown by cell culture. The cells formed many small-sized neutrophil colonies with G-CSF stimulation. Interestingly, they formed mainly neutrophil colonies with GM-CSF stimulation. These findings were different from those of chronic myelomonocytic leukemia cells and chronic granulocytic leukemia cells. This aCML case showed the cytological features of myelodysplastic syndrome.

Radiosurgery for bilateral neurinomas associated with neurofibromatosis type 2

OBJECTIVE

The clinical course of bilateral acoustic tumors associated with neurofibromatosis (NF2) is generally troublesome, and no definite treatment strategy has been established. Follow-up results of bilateral acoustic tumors after radiosurgery are reported herein.

METHODS

The current indications for radiosurgery are 1) a growing tumor less than 30 mm in mean diameter, 2) the ipsilateral ear has no serviceable hearing, and 3) there is risk of brain stem compression or brain stem dysfunction. Twenty cases of bilateral acoustic tumors were treated with the gamma knife, including 7 males and 13 females. The mean age was 38.2 years and the mean tumor size 24.4 mm. The tumors were treated with mean maximum and marginal doses of 26.8 Gy and 13.0 Gy, respectively. Among them, 12 patients had profound hearing loss in the ipsilateral (treated) ear, but the other 8 had serviceable hearing.

RESULTS

Tumors treated with radiosurgery showed central necrosis in 60% of the cases at 6 months and in 70% at 9 months after radiosurgery. Thereafter, the tumors often demonstrated slow regression. The rate of tumor shrinkage was 20% at 12 months, 35% at 24 months, and almost 60% at 36 months. At the last follow-up (mean 33.6 months), the tumors demonstrated shrinkage in 50% and tumor control in 100%. The contralateral tumors were stable in 12 (60%) and enlarged in 8 (40%). Preservation of serviceable hearing ipsilaterally was obtained in 33.3%. Deterioration of ipsilateral facial nerve function, either in the natural course or as a complication, occurred in 10%.

CONCLUSIONS

Because of good tumor control and tumor shrinkage as well as an acceptable complication rate, radiosurgery should be incorporated in the treatment strategy for bilateral acoustic tumors associated with NF2.

Gamma Knife radiosurgery for epilepsy associated with cavernous hemangiomas: a retrospective study of 49 cases

A retrospective multicenter study was performed to evaluate the effectiveness of Gamma Knife radiosurgery (GKRS) in the treatment of drug resistant epilepsy associated with cavernous hemangiomas (CH). The mean duration of epilepsy before GKRS was 7.5 ¿ 9.3 years. The mean frequency of seizures was 6.9 ¿ 14/month. The mean marginal dose was 19.2 ¿ 4.4 Gy (range 11.3 to 36 Gy). The mean follow up was 23.7 ¿ 13 months. At the most recent follow-up examination, 26 (53%) patients were seizure-free (Engel s class I) including 24 in class IA (49%) and two (4%) patients with occasional auras (class IB, 4%). A highly significant decrease in the number of seizures was achieved in 10 (20%) patients, which is class lIB. The remaining 13 (2.6%) patients showed little or no improvement. A medial temporal location was associated with a higher risk of failure. In contrast, all patients with central region CH were seizure free. Two severe but transient complications were observed. There was hemorrhage in one patient and another patient suffered from radio-induced edema with transient aphasia. This series is the first demonstrating that GKRS can be used safely and efficiently to treat epilepsy associated to CH. Seizure control can be reached when a good electro-clinical correlation exists between CH location and epileptogenic zone. Our findings suggest that GKRS can be used to treat epilepsy for CH located in highly functional areas, particularly the central region.

Glycogen storage disease type Ib: structural and mutational analysis of the microsomal glucose-6-phosphate transporter gene

Glycogen storage disease type Ib is caused by a mutation in the gene encoding microsomal glucose-6-phosphate (G6P) transporter. We determined the exon/intron organization of the G6P transporter gene. Four overlapping genomic fragments containing the entire coding region of the gene were amplified by polymerase chain reaction (PCR) using exonic primers, and their nucleotide sequences were determined. The gene spans 4.5 kb and has eight exons. All exon/intron boundaries adhered to the canonical AG/GT rule. We then designed eight pairs of PCR primers to amplify all coding exons for a mutational analysis and studied five Japanese patients with the disease. Two novel homozygous mutations were identified in two families: a three-base deletion (delV235) in exon 2 in a consanguineous family and a splicing mutation (IVS7+1G-->T) in intron 7 in a nonconsanguineous family. Patient 3 was a compound heterozygote of W118R and IVS1+1G-->A, both of which we previously identified [Kure et al., 1998: Biochem Biophys Res Commun 248:426-431]. Patients 4 and 5 were homozygotes of W118R. Including our previous study, we found a total of ten W118R alleles in nine Japanese patients. The results support our previous suggestion that W118R is prevalent among Japanese patients. The genomic sequence data and mutation spectrum obtained from the Japanese patients will facilitate genetic diagnosis of glycogen storage disease type Ib.

The management of bleeding peptic ulcer in the elderly with heater probe thermocoagulation

BACKGROUND/AIMS

The aim of this study was to compare the clinical characteristics of bleeding peptic ulcers in the elderly with those in younger patients, retrospectively.

METHODOLOGY

Between 1986 and 1994, 274 patients with bleeding peptic ulcers were treated with heater probe endoscopically. They were divided into 2 groups: 48 in the elder group (70 years of age or older) and 226 in the younger group (<70). We evaluated the rate of concomitant disease, rebleeding rate, incidence of emergency surgery, mortality and blood transfusion requirement between the 2 groups.

RESULTS

The incidence of concomitant disease was significantly higher in the elderly group (83.3%) than in the younger group (33.3%) (p<0.01). The rate of rebleeding (younger group 23.5% vs. elderly group 31.3%), the incidence of emergency surgery (5.8% vs. 6.3%, respectively) and the rate of mortality due to hemorrhage (2.2% vs. 4.2%, respectively) were similar in the 2 groups. There was no significant difference in the mean volume of blood transfused.

CONCLUSIONS

It was revealed that aggressive endoscopic hemostasis improved the mortality rate and the incidence of emergency surgery in elderly patients as well as in younger patients, provided that their general condition was monitored carefully.

Radiosurgery of angiographically occult vascular malformations

Angiographically occult vascular lesions (AVOMs) are vascular lesions not visualized on standard cerebral angiography. The possibility of managing these difficult lesions with radiosurgery is discussed. The radiosurgical treatments and results of AVOMs are described and the strategies for managing AOVMs and cavernous malformations are discussed.

K-ras point mutations in the supernatants of pancreatic juice and bile are reliable for diagnosis of pancreas and biliary tract carcinomas complementary to cytologic examination

In order to clarify whether DNA analysis for K-ras mutation can be used to diagnose cancers in supernatants of pancreatic juice and bile, samples from 29 cases of pancreatic, biliary tract, gastric, and neuroendocrine carcinomas, 1 malignant lymphoma case, 2 cases of pancreatic adenoma, 9 cases of chronic pancreatitis and 21 other non-cancer cases were examined. Polymerase chain reaction (PCR) products for K-ras gene codons 2 to 97 of exons 1 and 2 were generated with 33/33 (100%) pancreatic juice and 41/41 (100%) bile samples. By the single strand conformation polymorphism (SSCP) method, point mutations were detected in the pancreatic juice or bile supernatants of 13/13 (100%) pancreas cancer cases, 5/14 (35.7%) biliary tract cancer cases, 1/2 (50.0%) pancreatic adenoma cases and 3/9 (33.3%) chronic pancreatitis cases. Direct sequencing confirmed identical point mutations in the supernatants, malignant cells of cytologic smears of pancreatic juice or bile and cancer tissues. The DNA analysis demonstrated the presence of K-ras point mutations in 3 cases of pancreatic carcinomas with false-negative cytologic diagnoses. This novel method allows simultaneous testing for genetic abnormalities in supernatants of pancreatic juice and bile, after removing cells for cytologic diagnosis and screening for pancreatic and biliary tract tumors.

[Two cases of facial neurinoma successfully treated with gamma knife radiosurgery]

Two cases of facial neurinoma successfully treated with gamma knife radiosurgery are reported. Case 1, a 33-year-old female, developed a right-sided hemifacial spasm about five years ago. Then she suffered gradual progression of right-sided facial palsy, dysgeusia and reduction of lacrimation, but she had no hearing disturbance. T1-weighted MRI with gadolinium DTPA showed a well-circumscribed tumor at the geniculate ganglion extending to the middle cranial fossa. The tumor was treated with gamma knife radiosurgery which reduced its size, but didn't reduce the patient's facial palsy. Case 2, a 36-year-old female, presented with fluctuating facial palsy and sensorineural hearing loss lasting for fourteen years. T1-weighted enhanced MRI showed a well-enhanced tumor at the CP angle extending to the middle cranial fossa. The tumor was treated with gamma knife radiosurgery, which caused central tumor necrosis, but didn't reduce the tumor size. Meanwhile the patient's facial palsy improved. Gamma knife radiosurgery is apparently effective against facial neurinomas without producing serious complications such as complete facial palsy and hearing loss. Our study indicates that gamma knife radiosurgery is a useful therapeutic alternative for facial neurinomas.

Treatment of the survivors from the Nagoya air crash

Six patients were taken to our hospital alive just after the air crash at Nagoya Airport in 1994. On admission, all patients suffered from profound shock which rapidly progressed. Serum albumin and hemoglobin levels, and platelet count decreased on admission or soon after. The four patients who died could not recover from the shock and associated rapid deterioration of neurological signs. However, two patients were successfully treated with massive transfusion of packed red blood cells, fresh frozen plasma, fresh blood, and/or platelet concentrate and survived to discharge. We recommend addition of albumin to the transfusate in such cases.

Three siblings of fatal infantile encephalopathy with olivopontocerebellar hypoplasia and microcephaly

We report three male siblings born with fatal encephalopathy comprising microcephaly, myoclonus and muscle hypertonia. All three patients died during infancy. Postmortem examination on the brain revealed that all infants had neuronal loss in the cerebellar cortex, inferior olivary and pontine nuclei, which were more pronounced in the older subject than the younger ones. In addition, they were associated with polymicrogyria in the cerebral cortex of the insula, olivary and dentate nuclear dysplasia, and a hypoplastic corticospinal tract. The clinical and neuropathological findings in our cases were identical to those in fatal infantile encephalopathy with olivopontocerebellar hypoplasia and microencephaly [Albrecht et al., Acta Neuropathol 1993;85:394-399], but an association of malformations suggests a new genetic factor in pathogenesis of olivopontocerebellar hypoplasia.