[Surgical stabilization of multiple rib fractures successfully achieved with the use of long metalic plates]

Surgical stabilization of multiple rib fractures in 5 male patients was successfully achieved with the use of orthopedic A-O metalic plates, which are called reconstruction plates. In each patient, we prevented deformity of the rib cage and flail chest which frequently occurs after multiple rib fractures. Three of these patients received emergency operations because of severe hemopneumothorax and flail chest due to crushing injuries to the chest. They were treated by the standard thoracotomy, hemostasis of intrapleural bleeding, and stabilization of fractured ribs with reconstruction plates, in addition two of the patients underwent a single lobectomy to control the pulmonary hemorrhage. Another two patients were treated with mechanical ventilation and closed-tube thoracotomy following the chest trauma because their thoracic bleeding from drainage tubes was tolerable. But flail chest and respiratory insufficiency did not improve, in spite of positive controlled ventilation as a mode of internal pneumatic stabilization. Then surgical stabilization of the fractured ribs with these plates was carried out ten to twelve days after the accidents in each case. All patients tolerated the surgical procedures well and were successfully removed from the respirator, demonstrating complete stability of the chest wall. The long metal reconstruction plates with many perforations were very useful for the external fixation of segmentary fractured ribs as an external brace. This was because they were long enough to cover the whole length of the fractured ribs and moderately soft enough to be appropriately bent or twisted by hand at the time of operation. Moreover a number of holes in it allowed the suture to pass through the plate and rib, avoiding displacement of the prosthesis. This is the first report which describes the usefulness of orthopedic reconstruction plates for the stabilization of multiple rib fractures.

Effect of ceramic surface treatments on the bond of four resin luting agents to a ceramic material

PURPOSE

This study evaluated the effect of various ceramic surface treatments on the shear bond strengths of four resin luting agents to Cerec 2 ceramic material.

MATERIAL AND METHODS

Four ceramic surface treatments were performed. All groups were subjected to the control treatment, which was abrasion with No. 600 silicon carbide paper. The other three group treatments were etching with phosphoric acid gel, application of bonding agent containing silane coupler, and application of silane coupling agent after etching with phosphoric acid gel. Cerec 2 ceramic specimens were treated with one of the four methods and then cemented together with each of the four resin luting agents (Super-Bond C&B, Panavia 21, Clapearl, and Vita Cerec Duo Cement). Half of the specimens were stored in water and the other half were thermal cycled before shear bond strength testing.

RESULTS

Treatment with the silane coupler improved the shear bond strength compared only with the abrasion with carbide paper (control). When the ceramic material was treated with the silane coupler or the silane coupling agent after etching with phosphoric acid gel, no significant differences in bond strength were noted between water storage and 20,000 thermal cycles for any of the four resin luting agents. After 20,000 thermal cycles, all specimens treated with the silane coupling agent with phosphoric acid gel except those cemented with Super-Bond C&B resin luting agent after etching showed cohesive failures within the ceramic.

CONCLUSION

Combined surface treatment of etching with phosphoric acid and application of silane coupling agent provides the highest bond strengths of resin luting agents to Cerec 2 ceramic material after thermal cycling.

[Correlation of pathological features of surgically excised choroidal neovascular membranes with age-related macular degeneration and indocyanine green videoangiographic findings]

We surgically excised subfoveal neovascular membranes from eight patients with age-related macular degeneration. The correlation of the histopathological features of choroidal neovascularization and preoperative indocyanine green (ICG) videoangiographic findings were studied. Neovascular membranes which demonstrated hyperfluorescence at an early phase of ICG videoangiography had many vascular channels and a large lumen without enclosure of retinal pigment epithelium (RPE). Fibrovascular tissues contained small vessels with fibrotic stroma that showed hyperfluorescence only at a late phase of ICG videoangiography. In contrast, the membrane which showed hypofluorescence of ICG videoangiography was composed of paucivascular fibrotic tissue covered extensively with RPE. Moreover, newly formed vessels with proliferative endothelium could be observed in the neovascular membranes that showed weak fluorescence or hypofluorescence. These results could provide a morphological basis for the interpretation of ICG videoangiographic features of choroidal neovascularization. It also may be useful in planning the treatment for subfoveal neovascular membranes.

Localization analysis of neuronal activities in benign rolandic epilepsy using magnetoencephalography

Benign epilepsy of childhood with rolandic spikes (BECRS) is an electroclinical syndrome characterized by partial sensorimotor seizures with centrotemporal spikes. We report a detailed localization analysis of spontaneous magnetic brain activities in seven BECRS patients using magnetoencephalography (MEG). All patients had BECRS diagnosis with typical seizures and electroencephalographic findings and five patients had minor psychomotor deficits. MEG was recorded over both parieto-temporal regions using a 2x37-channel biomagnetic system. The collected data were digitally bandpass-filtered (2-6, 14-30, or 1-70 Hz) to analyze slow- and fast-wave magnetic activities and rolandic spikes. Slow-wave activity was increased in four hemispheres of three patients. Increased fast-wave activity was found in all five patients with minor neuropsychological deficits. The presence of increased fast-wave magnetic brain activity appeared to cause functional anomalies in the higher brain function processes. In the spike analysis, the dipoles of rolandic spikes which constantly manifested anterior positivity in direction were concentrated in the superior rolandic region in four cases and the inferior rolandic region in three cases. The localizations of increased slow- and fast-wave activities were identical with those of the spikes. The seizure profiles were frequently characterized by the spike locations. Source localizations of the focal brain activities and rolandic spikes by MEG will contribute to the different diagnosis and pathophysiological elucidation of BECRS.

[Wide resection and reconstruction of chest wall: usefulness of A-O metal plate]

A 53-year-old male was admitted to our department with a chest tumor due to infiltration of lung cancer. Right upper lobectomy and a wide en bloc excision of the right upper chest wall were performed, including the 2nd, 3rd, 4th, and 5th ribs with upper lobectomy of right lung. The defect was replaced with three A-O metal plates, which joined both stumps of the ribs, from the third to the fifth rib. These metal plates were very useful because it was easy to bent and twist them to fit the defect in operation. And curved metal plates preserved a cone from of chest cage. Postoperative course was favourable without mechanical ventilation and wound infection.

Functional and metabolic analysis of cerebral ischemia using magnetoencephalography and proton magnetic resonance spectroscopy

The details of the relationship between brain function and metabolism in brain infarcts have not been studied. Using magnetoencephalography (MEG) and proton magnetic resonance spectroscopic imaging (1H MRSI), we localized sources of abnormal magnetic activities in ischemic brain regions and biochemical changes in suspected lesions showing pathological characteristics. Twelve patients with ischemic stroke were examined and the results of MEG and 1H MRSI were superimposed onto the corresponding MR images. The signal intensities of N-acetyl (NA) and lactate (Lac) were measured in the lesions with highly concentrated dipoles of slow wave activity. Eleven of 12 cases had increased slow wave activity in the cortical areas adjacent to the infarcts; 1 case was excluded because the infarct was too small (<1 cm in diameter). The signal intensity of NA in the regions with the highest slow wave activity was significantly reduced and was well correlated with the dipole density of slow waves. Though Lac was mildly accumulated in the lesions, the Lac level had no correlation with slow wave magnetic activity. The remaining and metabolically active cortical tissue showing NA signal produced the abnormal slow wave activity under lactic acidosis (mild accumulation of Lac).

Metabolic and neurological patterns in chronic cerebral infarction: a single-voxel 1H-MR spectroscopy study

The details of brain metabolism in chronic cerebral infarcts have not been clarified. Using proton MR spectroscopy (1H-MRS) at 1.5 T, we measured biochemical changes in 16 patients with large infarcts involving the motor cortex in the chronic phase (median 293.9 days) and related the findings to clinical data. Localised spectra were obtained using point-resolved spectroscopy, with an echo time of 270 ms. Regions of interest were placed on the frontal lobe, including the precentral gyrus and central sulcus. Motor function was assessed by the manual muscle power test at the time of the 1H-MRS study. Only three patients with severe paresis had no signal in the lesions and a lactate signal was obtained in 13 cases. N-acetyl aspartate (NAA) was observed in 4 cases with recanalisation of an occluded vessel. Motor function correlated strongly with the NAA/choline-containing compounds (Cho) ratio (P < 0.01) and lactate/Cho ratio (P < 0.01). We found various metabolic patterns, reflecting residual neurological function.

Intraorbital subperiosteal hematoma due to paranasal mucocele--case report

A 68-year-old female was admitted with a rare intraorbital subperiosteal hematoma manifesting as sudden orbital pain, progressive blepharoptosis, and diplopia. Computed tomography showed a biconvex high density mass in the superomedial part of the left orbit, which was recognized to be a subperiosteal hematoma intraoperatively. The eroded orbital roof between the frontal sinus and orbit was a result of mechanical compression by the mucocele. Infection extending into the orbit was important in causing the hemorrhage.

[Transfusion of autologous deposited blood in support of surgery for cerebral aneurysm evaluated by screening for occult intracranial disease]

Preoperatively donated autologous blood was transfused during surgery of an unruptured cerebral aneurysm in a 63-year-old banker to avoid allogeneic blood exposure. The aneurysm in this case was evaluated by noninvasive screening for occult intracranial disease. The transfusion was based on the Red Cross Blood Transfusion Service autologous donor programme for regional hospitals. Preoperative autologous blood donation has continued to grow to reduce risks such as infectious disease transmission and post-transfusion graft-versus-host disease. It is an alternative transfusion practice that should become a standard of care for elective neurosurgery especially in preventive medicine.

[Ruptured traumatic aneurysms of the peripheral anterior cerebral artery: study of delayed hemorrhage after closed head injury]

We report three cases of ruptured traumatic aneurysms of the peripheral anterior cerebral artery after closed head injury. These cases were all young men with closed head injury due to traffic accidents. Consciousness level on admission was coma in all three cases. Case 1 was a 19-year-old man with interhemispheric hematoma on initial CT, then 7 days later his consciousness cleared. However, 14 days later he suddenly lapsed into a deep coma with a severe frontal hemorrhage. Case 2 was a 13-year-old boy. Plain skull films demonstrated a frontal depressed fracture, but CT scan showed no bleeding. Four days later his consciousness cleared but 11 days after trauma, he lapsed into a deep coma with a frontal hemorrhage. Case 3 was a 22-year-old man. Initial CT showed a slight ventricular hemorrhage. Fourteen days later, his consciousness had almost cleared, but then he lapsed into a deep coma with a large frontal hemorrhage 11 weeks after the trauma. These patients all died within a few days after intracranial bleeding. All patients underwent cerebral angiography but none of them showed filling defect. Autopsy was performed and ruptured aneurysms were found on the distal anterior cerebral artery that had no relation to the branch of bifurcation. Histological examination demonstrated a lack of elastic lamina and media in all of these three cases, so each of them was a victim of so-called false aneurysm. Twenty reported cases of ruptured traumatic aneurysms of the peripheral cerebral artery with delayed hemorrhage after closed head injury were reviewed. Factors in the traumatic aneurysm showed no relation to the duration of disturbed consciousness. Within one month, delayed hemorrhage due to ruptured traumatic aneurysm occurred. None of the delayed hemorrhages involved subarachnoid hemorrhage. Subdural hematoma was seen in the distal middle cerebral artery and frontal hemorrhage was found in the distal anterior cerebral artery. We consider that frontal hemorrhage is a predictive finding for the type of delayed hemorrhage due to traumatic aneurysm in the distal anterior cerebral artery.

Differentiation of cerebral radiation necrosis from tumor recurrence by proton magnetic resonance spectroscopy

Proton magnetic resonance spectroscopy (1H MRS) was evaluated for distinguishing between radiation necrosis and recurrent glioma in 11 patients after high-dose radiotherapy. Six patients had a histological diagnosis of recurrent glioma. Four patients had a histological diagnosis of radiation necrosis and one had a clinical course consistent with the diagnosis of radiation necrosis. 1H MRS showed cases of radiation necrosis had two characteristic 1H MRS patterns: markedly increased lactate/creatine and phosphocreatine (Cr) ratio and decreased choline-containing compounds/Cr ratio compared to that of recurrent glioma; or all the major metabolites were completely diminished. The N-acetyl aspartate signal was not helpful for differential diagnosis. 1H MRS is a potentially useful method for differentiating tumor recurrence from radiation necrosis in patients treated for malignant glioma.

Characteristics of intracranial aneurysms associated with moyamoya disease. A review of 111 cases

A retrospective analysis of 111 patients with aneurysms associated with Moyamoya disease is presented. The subjects comprised of our 12 cases and 99 other well-documented cases. These 111 cases had 131 aneurysms. There were 48 males and 63 females. The average age was 40.3 years. The clinical manifestations were intracranial haemorrhage in 99 cases (89%), and ischaemic events in 9 cases (8%), but no mention was made of these in the last three cases (2%). The Hunt and Kosnik grades were grade 1 in 8%, grade 2 in 23%, grade 3 in 31%, grade 4 in 35%, and grade 5 in 3%. Of the 131 aneurysms, 73 (56%) were found distributed around the circle of Willis, 24 (18%) in the basal ganglia, 29 (22%) on collateral vessels, and 5 (4%) on other vessels. Forty-six percent of the cases were treated surgically, 51% conservatively, and 3% by endovascular procedures. The surgical procedures for the aneurysms were; neck clipping in 49%, aneurysmectomy in 18%, wrapping of the aneurysm in 11%, coating or cautery of the aneurysm in 7%, and revascularization only in 11%. The outcomes were Glasgow Outcome Scale 1 in 30%, 2 in 22%, 3 in 11%, 4 in 1%, and 5 in 25%. The main reasons for the unfavourable outcome were initial poor clinical grade and rebleeding. Follow-up angiography of 25 aneurysms demonstrated that all aneurysms in the basal ganglia or on the collateral vessels disappeared. We recommend surgical intervention for aneurysms associated with Moyamoya disease to prevent rupture or rebleeding, especially for aneurysms around the circle of Willis. However, direct surgery is not recommended for aneurysms found in the basal ganglia or on the collateral vessels.

Structure of a replication-terminator protein complexed with DNA

The crystal structure of the Escherichia coli replication-terminator protein (Tus) bound to terminus-site (Ter) DNA has been determined at 2.7 A resolution. The Tus protein folds into a previously undescribed architecture divided into two domains by a central basic cleft. This cleft accommodates locally deformed B-form Ter DNA and makes extensive contacts with the major groove, mainly through two interdomain beta-strands. The unusual structural features of this complex may explain how the replication fork is halted in only one direction.

Clinical features of the haemorrhage type moyamoya disease based on 31 cases

We evaluated and analysed our own 31 cases of the haemorrhagic type of moyamoya disease to clarify the clinical features of this disease. The cases were divided into three groups. Group A consisted of 12 cases with aneurysms. Aneurysms on the circle of Willis were treated as ordinary saccular aneurysms. Group B consisted of 14 cases with intracerebral haemorrhage (ICH) without aneurysms. These were managed almost as spontaneous ICH. Group C consisted of 5 cases with intraventricular haemorrhage (IVH) without aneurysms or ICH. Twenty-two surgical procedures for aneurysms, ICH and IVH were done in 19 cases (62%). Nineteen procedures for preventing future strokes were undertaken in 11 cases (35%). The overall initial outcome was excellent in 12 cases (39%), good in 7 cases (23%), poor in 7 cases (23%), and death in 5 cases (15%). During the follow-up period (mean: 6.5 years), rebleeding occurred in two cases (8%), and ischaemic attacks in two cases (8%). The rate of rebleeding or ischaemic attacks was 1.19% per patient-year during the follow-up period. There was no ischaemic or rebleeding episode in cases treated by STA-MCA bypass with encephalomyosynagiosis (EMS) during the follow-up period. Management of the primary haemorrhage should be according to the clinical condition, type of haemorrhage, and source of haemorrhage. When the patient needs to undergo revascularization surgery to prevent future strokes, we recommend STA-MCA bypass with EMS instead of encephaloduro-arteriosynangiosis (EDAS).

[Posterior fossa dural arteriovenous fistula with progressive disorder of cerebellar circulation; case report]

A rare case of posterior fossa dural arteriovenous fistula with cerebellar circulation disorder is reported. A 64-year-old male was admitted to a hospital with complaints of nausea, vertigo and mild headache. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed cerebellar infarction. Then, he was sent to our hospital. He had complaints of cerebellar signs and nystagmus. Cerebral angiography showed dural AVF of the posterior fossa and occlusion of the left transverse-sigmoid sinuses. Because his condition deteriorated, embolization of the left middle meningeal artery, ascending pharyngeal artery and occipital artery was performed selectively on August 18. Subsequently, isolation of dural AVF was performed on August 19. After the operation he improved and was able to walk with a stick. Controlled angiography revealed the disappearance of dural AVF. This case suggested that AV shunt is essential for the progression of venous infarction.

Shear bond strengths of three resin cements used with three adhesive primers for metal

This study compared the durability and shear bond strengths of combinations of three adhesive primers and three resin cements bonded to silver-palladium-copper-gold (Ag-Pd-Cu-Au) and cobalt-chromium (Co-Cr) alloys. The adhesive luting cements Imperva Dual, Panavia 21, and Super-Bond C&B and the adhesive primers Metal Primer material, V-Primer material, and Cesead Opaque Primer material were used. The application of Metal Primer material was effective in improving the shear bond strengths between each of the three resin cements and Ag-Pd-Cu-Au alloy compared with nonprimed specimens. Co-Cr alloy primed with Cesead Opaque Primer, followed by cementation with Imperva Dual or Super-Bond C&B luting cements yielded the strongest shear bond strengths after 50,000 thermocycles, and Panavia 21 cement did not reveal any significant differences in bond strengths between nonprimed specimens and those primed with Cesead Opaque Primer at all thermocycles.

Crystallization and preliminary X-ray analysis of the Escherichia coli replication terminator protein complexed with DNA

Crystals of the Escherichia coli replication terminator protein (Tus) complexed with its binding site DNA were obtained by a microdialysis method using PEG 4000. They belong to the tetragonal space group P4(1)2(1)2 or P4(3)2(1)2 with the unit cell parameter: a = 68.1 A, c = 230.7 A and contain one protein-DNA complex in an asymmetric unit. The native data set has been collected to 2.7 A resolution.

Proton magnetic resonance spectroscopy in patients with glial tumors: a multicenter study

The authors represent a cooperative group of 15 institutions that examined the feasibility of using metabolic features observed in vivo with 1H-magnetic resonance (MR) spectroscopy to characterize brain tumors of the glial type. The institutions provided blinded, centralized MR spectroscopy data processing long with independent central review of MR spectroscopy voxel placement, composition and contamination by brain, histopathological typing using current World Health Organization criteria, and clinical data. Proton 1H-MR spectroscopy was performed using a spin-echo technique to obtain spectra from 8-cc voxels in the tumor and when feasible in the contralateral brain. Eighty-six cases were assessable, 41 of which had contralateral brain spectra. Glial tumors had significantly elevated intensities of choline signals, decreased intensities of creatine signals, and decreased intensities of N-acetylaspartate compared to brain. Choline signal intensities were highest in astrocytomas and anaplastic astrocytomas, and creatine signal intensities were lowest in glioblastomas. However, whether expressed relative to brain or as intratumoral ratios, these metabolic characteristics exhibited large variations within each subtype of glial tumor. The resulting overlaps precluded diagnostic accuracy in the distinction of low-and high-grade tumors. Although the extent of contamination of the 1H-MR spectroscopy voxel by brain had a marked effect on metabolite concentrations and ratios, selection of cases with minimal contamination did not reduce these overlaps. Thus, each type and grade of tumor is a metabolically hetero-geneous group. Lactate occurred infrequently and in all grades. Mobile lipids, on the other hand, occurred in 41% of high-grade tumors with higher mean amounts found in glioblastomas. This result, coupled with the recent demonstration that intratumoral mobile lipids correlate with microscopic tumor cell necrosis, leads to the hypothesis that mobile lipids observed in vivo in 1H-MR spectroscopy may correlate independently with prognosis of individual patients.

Intra-operative monitoring by facial electromyographic responses during microvascular decompressive surgery for hemifacial spasm

The facial electromyographic response was monitored intraoperatively in 40 patients with hemifacial spasm who were operated on by microvascular decompression of the facial nerve. All 40 patients showed an abnormal facial electromyographic response (lateral spread response) with a latency of about 10 msec after stimulation. The abnormal response resolved before decompression in 22, resolved immediately with decompression in 16, and failed to resolve in two. Of the 38 patients in whom the abnormal response disappeared during surgery, 36 were postoperatively free from hemifacial spasm and two had mild hemifacial spasm. The two patients in whom the lateral spread response did not disappear during surgery showed persistent hemifacial spasm. In conclusion. Disappearance of the lateral spread response during surgery correlated with the absence of hemifacial spasm in the early postoperative period. The prognosis of hemifacial spasm was good in cases in whom the lateral spread response disappeared. Therefore, the authors think that intra-operative facial electromyography is very useful in assessing the efficacy of microvascular decompression and in predicting the prognosis of hemifacial spasm.

[Sequential observations of brain edema with proton magnetic resonance imaging and spectroscopy]

The purpose of this study was to assess the relationship between morphological and metabolic changes in brain edema using proton magnetic resonance systems. The serial changes during the first 24 hours in the cold-injury trauma rat brain model were investigated by proton magnetic resonance imaging (1H MRI) and high-resolution proton MR spectroscopy (1H MRS). We also analyzed the efficacy of AVS 1,2-bis (nicotinamide)-propane which can scavenge free radicals to the edema in this experiment. The edema was developing extensively via the corpus callosum in ipsi- and contralateral hemispheres as shown by gradually increased signal intensity on 1H MRI. 1H MRS initially showed accumulation of acetate and lactate, and transient increasing of glutamine. After 24 hours, the increased glutamine decreased below the control, alanine increased, and N-acetyl asparatate decreased with the edema development. AVS-treatment significantly suppressed edema development, increases of lactate and alanine and decreases of N-acetyl asparatate. We suggest that the cold-induced lesion contains anaerobic glycolysis deterioration and results in severe brain tissue breakdown. AVS is proved valuable for the treatment of this edema lesion. Clinical 1H MRS showed prolonged lactate elevation and significant decreases of other metabolites in human ischemic stroke edema. In peritumoral edema, decreased N-acetyl asparatate gradually improved, and slightly elevated lactate disappeared after tumor removal. 1H MRS feasibly characterizes the ischemic and peritumoral edema and makes a quantitative analysis in human brain metabolism. We believe the combined 1H MRI and MRS study is a practical method to monitor the brain conditions and will make it easy and possible to find new therapeutic agents to some brain disorders.