Brain perfusion SPECT in a patient with a subtle venous angioma

Brain SPECT of regional cerebral blood flow using I-123 IMP demonstrated a focally decreased perfusion area immediately adjacent to a venous angioma in a patient with simple partial seizures. A positive correlation was obtained among the location of the venous angioma, the decreased perfusion area on SPECT images, and the electroencephalographic focus. Anomalous venous drainage through a venous angioma may explain a perfusion disturbance in the surrounding brain of the angioma. High-resolution SPECT imaging with magnetic resonance guidance provides useful information on the pathophysiology of venous angiomas.

Altered postprandial insulin requirement in IDDM patients with gastroparesis

OBJECTIVE

To evaluate the effect of gastric emptying on postprandial insulin requirement in insulin-dependent diabetes mellitus (IDDM) patients with and without gastroparesis.

RESEARCH DESIGN AND METHODS

Postprandial insulin requirement and gastric emptying were simultaneously evaluated in five IDDM patients with gastroparesis and in six control IDDM patients without gastroparesis. Postprandial insulin requirement after test-meal intake was assessed by measuring the insulin infusion rate during a 4-h feedback control with an artificial endocrine pancreas device (Biostator, Life Science Instruments, Miles, Elkhart, IN). Gastric solid and liquid emptyings were evaluated during the Biostator study by measuring the disappearance rate of 99mTc in the stomach and in the time course of plasma acetaminophen concentration, respectively.

RESULTS

Total insulin requirement during the first 120 min after the test-meal intake was significantly lower in the gastroparetic patients than in the control patients. The gastroparetic patients showed no apparent postprandial peak for insulin infusion rate during the 4-h study, although the peak rate was observed within 120 min after the test-meal intake in the control patients. The disappearance of 99mTc in the stomach was significantly slower, and plasma acetaminophen concentrations were significantly lower in the gastroparetic patients compared with those in the control patients, respectively.

CONCLUSIONS

The results suggest that IDDM patients with gastroparesis, accompanied by impaired solid and liquid emptying, have an altered postprandial insulin requirement.

Lipoprotein(a) as an independent risk factor for diabetic retinopathy in male patients in non-insulin-dependent diabetes mellitus

Relationship of the lipoprotein(a) [Lp(a)] concentration as a risk factor independent of other factors with the severity of diabetic retinopathy were evaluated by multiple regression analysis. The subjects were 158 patients with non-insulin-dependent diabetes mellitus (NIDDM). Multiple regression analysis was carried with the severity of diabetic retinopathy as the dependent variable and 13 independent variables, namely the Lp(a) concentration, sex, age, body mass index, duration of diabetes, ischemic heart disease, fasting plasma glucose, glycosylated hemoglobin A1c, total cholesterol, triglyceride, high-density lipoprotein cholesterol, anti-diabetic treatments, and diabetic nephropathy. The analysis was performed separately in all subjects, males only, and females only. The standard partial regression coefficient of Lp(a) was significant (0.293, p < 0.01), and the multiple correlation coefficient was 0.611 in the males. However, the standard partial correlation coefficient of Lp(a) was not significant in all patients and in females only. The rank of contribution of Lp(a) to retinopathy was the third in males, following triglyceride and nephropathy and followed by anti-diabetic treatments. These results suggest that Lp(a) might be an independent risk factor for diabetic retinopathy in male patients with NIDDM.

[Changes in the beta-receptor density and its responsiveness to beta-agonist in rabbit myocardium during hemorrhagic shock]

We studied change of the beta-receptor density and its responsiveness to beta-agonist in rabbit myocardium during hemorrhagic shock. We found that down-regulation of beta-receptor in the myocardium appears after hemorrhagic shock of approximately 180 minutes and inversely, defense mechanism of the organism comes in by increasing its the affinity. With regard to the responsiveness of beta-agonist, decrease in the elevating rate of cyclic adenosine monophosphate (c-AMP) was already recognized after 30 minutes of the hemorrhagic shock, and not only c-AMP, but also functional decrease of the response was recognized after 180 minutes. The results suggest that beta-adrenergic system can not function because of remarkable metabolic acidosis if the hemorrhagic shock is left untreated for from 30 to 180 minutes.

Three types of "mid-band" lipoproteins in non-insulin-dependent diabetes mellitus: relation to metabolic abnormalities and vascular complications

A number of fine bands which occur in positions between the beta- and pre-beta-lipoproteins in polyacrylamide gell electrophresis are called mid-bands (MB). In this study, the relationship between the occurrence of these MB and metabolic abnormalities or vascular complications was evaluated in 181 patients with non-insulin-dependent diabetes mellitus (NIDDM). The incidence of MB in diabetic patients was significantly higher than that in 149 healthy control subjects (35 vs. 20%, p < 0.01). Analysis according to the type of MB revealed that the incidence of the central type in diabetic patients was significantly higher than that in healthy control subject (11 vs. 5%, p < 0.05). When the values of HbAlc were elevated, the incidence of MB and its central type slightly increased. The occurrence of the lower type of MB showed no relationship with the levels of HbAlc. The incidence of MB and its central type were significantly higher in patients with type IIb hyperlipidemia (86 and 41%, respectively) and with type IV hyperlipidemia (63 and 25%) than in those with normolipidemia (21 and 5%) (p < 0.01 of all). The incidence of the lower type of MB was significantly higher in patients with type IIa hyperlipidemia (25%) and with type IIb hyperlipidemia (36%) than in those with normolipidemia (11%) (p < 0.05, p < 0.01, respectively). There was no significant difference in the occurrences of MB and of the central and lower types of MB between the normolipidemic patients and healthy control subjects. The incidence of MB and its central type were significantly higher in patients with nephropathy (54 and 23%, respectively) than in those without nephropathy (32 and 9%) (p < 0.05 of all). There was no significant difference in the incidence of lower type of MB between patients with and without nephropathy. These results indicate that the incidence of central type of MB may be high in NIDDM, and that the occurrence of central type may be associated with abnormal metabolism of glucose or lipid and with diabetic nephropathy.

Effects of zopiclone on sleep and symptoms in schizophrenia: comparison with benzodiazepine hypnotics

Sleep variables and psychiatric symptoms were investigated in 6 male chronic schizophrenic outpatients. The patients were being treated with benzodiazepine (BZD) hypnotics for more than 8 weeks, and BZDs were replaced with zopiclone (ZPC) 15 mg/day. Polysomnographic examinations, subjective sleep assessments and BPRS scoring were performed during BZD therapy and at the end of 8 weeks of ZPC therapy. The doses of neuroleptics and anticholinergic agents remained fixed throughout the study. The amount of slow-wave sleep (SWS) was markedly small and that of stage 1 sleep was moderately large during BZD therapy. The amount of stage 1 was smaller and that of stage 2 was larger during treatment with ZPC than BZDs. There were no significant change in the amount of SWS between the treatment. Half of the patients exhibited a sleep-onset REM period (SOREMP) during ZPC therapy. Both total BPRS score and negative symptom score were lower during treatment with ZPC than BZDs. These results suggest that ZPC may be more beneficial in treating schizophrenic insomnia than BZD hypnotics and that reduced SWS and SOREMP may be partly involved in the pathophysiology of schizophrenia.

Lipid composition of platelets in patients with non-insulin-dependent diabetes mellitus: studies before and after treatment of diabetes

The study was designed to investigate whether impaired composition of platelet lipids in untreated diabetic patients improved after diabetic treatment. Fourteen untreated patients with non-insulin-dependent diabetes mellitus (NIDDM) and 15 healthy control subjects were studied. In the diabetic patients, the ratio of free cholesterol to phospholipid (FC/PL) in platelets of 0.33 +/- 0.02 (mean +/- SEM) at pre-treatment, which was statistically (p < 0.05) higher than that of 0.26 +/- 0.02 in control subjects, was significantly decreased to the value of 0.29 +/- 0.02 (p < 0.01) after insulin therapy. Platelet FC level of 9.77 +/- 0.77 micrograms 10(-8) cells pre-treatment was significantly (p < 0.01) reduced to the value of 7.72 +/- 0.38 micrograms 10(-8) cells post-treatment. Platelet PL level showed no significant changes after the treatment. There was a significantly (p < 0.01) positive correlation between the decrease in FC/PL of platelets and that in haemoglobin A1c (HbA1c) after treatment for diabetes (rs = -0.729). These results indicate that the impaired lipid composition in platelets can be improved after an adequate glycaemic control in patients with NIDDM.

Clinical characteristics in non-insulin-dependent diabetic patients with long duration in Japan--relation to risk factors for vascular complications

In this study, we evaluated the control state of body weight, blood pressure, and blood glucose during the recent 10 years in 82 patients of non-insulin-dependent diabetes mellitus (NIDDM) who had long duration of diabetes for 20-25 years without ischemic heart disease (IHD) and diabetic nephropathy (Neph). The patients without either IHD or Neph showed significantly lower incidences of obese (11 vs. 40%, p < 0.05), hypertensive (0 vs. 20%, p < 0.05) and poor glycemic control state (7 vs. 27%, p < 0.05) for 10 years than the patients with IHD alone, and showed significantly lower incidences of hypertensive (0 vs. 20%, p < 0.05) and poor glycemic control state (7 vs. 33%, p < 0.01) than the patients with Neph alone. The control state of body weight was similar between the patients without either IHD or Neph and with Neph alone. In addition, the patients without either IHD or Neph showed significantly lower incidences of obese (11 vs. 56%, p < 0.01) and hypertensive control state (0 vs. 40%, p < 0.01) for 10 years than the patients with both IHD and Neph. The control state of blood glucose was similar between the two groups. These results suggest that for long survival of NIDDM patients without development or progression of IHD and Neph, non-obese and non-hypertensive state as well as good glycemic control should be maintained for long time.

[Brain metastasis of rhabdomyosarcoma with intratumorous hemorrhage: a case report and literature review]

A 56-year-old male suffered from primary rhabdomyosarcoma on the left internal thoracic wall, which was treated by chemotherapy, and local irradiation following biopsy. Four months after the diagnosis, he suddenly complained of headache and left paresthesia occurred followed by generalized convulsion and left hemiplegia. CT scan revealed a high density mass in the right parietal lobe. The patient was referred to our department and underwent emergency evacuation of the hematoma together with tumor removal. The pathological specimen showed spindle or oval-like cells with hypercellularity and some mitotic figures. Immunohistochemical study demonstrated that many cells were positive for desmin and myoglobin, which is specific to myogenic tumor. These characteristics were compatible with those of the primary thoracic lesion, and a diagnosis of metastatic rhabdomyosarcoma was made. Five weeks after the craniotomy, the metastatic brain tumor recurred in the same site and also in the bilateral occipital lobes. Although radiotherapy to the brain decreased the tumor size, the patient died of respiratory failure eleven and a half months after the initial diagnosis. Sarcomas metastasizing to the brain are rare and only 16 cases of rhabdomyosarcoma metastasizing to the brain have been reported so far. Recent advances in chemotherapy, however, have been able to show the increased incidence of sarcoma metastasis to the brain. Therefore, the necessity of follow-up CT scan for sarcoma patients of long survival is to be stressed, even if the patient shows no neurological symptoms.

[Clinical research of patients with epilepsy over age 50 years--a retrospective study of early onset case]

One hundred-sixteen patients with epilepsy over 50 years old were investigated to explore the clinical characteristics of epilepsy in elderly persons. Eighty-four patients having seizures within the last 3 years (residual group) were compared with 32 patients having no seizures within the last 3 years (disappeared group). Regarding the epilepsy type, there were 87 partial epilepsies (64 in the residual group and 23 in the disappeared group) which were approximately 70 percent of the total patients. Generalized epilepsies were comparatively rare in the both groups. Eleven patients with progressive myoclonus epilepsy were observed in the residual group. Regarding the seizure type, generalized convulsive seizures (GCS) were more likely to disappear than partial seizures regardless of number of seizures the patient had. Thirty-eight patients (29 in the residual group and 9 in the disappeared group) had histories of psychiatric problems. Paranoid states were most commonly seen in 12 patients in the residual group and 5 patients in the disappeared group. Intellectual disturbance was seen more frequently in the residual group.

Intracarotid amobarbital injection produces hippocampal EEG changes in patients with temporal lobe epilepsy

EEGs of hippocampi of both sides were analyzed during intracarotid amobarbital tests in 12 patients with temporal lobe epilepsy. The number of paroxysms occurring 1 min before the injection ipsilaterally and contralaterally was compared with that occurring 1 min after the injection. The hippocampal EEG ipsilateral to the injection showed an increase in paroxysms irrespective of the laterality of the epileptogenic side. Contralateral to the amobarbital injection an increase in paroxysms was observed in the epileptogenic hippocampus only.

Massive cerebral air embolism following cardiopulmonary resuscitation. Report of two cases

Cerebral air embolism can occur in a number of situations. We report two cases of massive cerebral arterial air embolism following cardiopulmonary resuscitation, and its mechanism is discussed.

[Penetrating injury of the common carotid artery: report of a case]

An eighty-year-old man slipped in the bathroom and received a deep slash wound in his left neck caused by a broken fragment of the bathroom door. A fragment of the glass stuck into his left neck. He was carried to our clinic after 20 minutes in a state of shock and showed right hemiparesis and aphasia. Following immediate orotracheal intubation and emergent therapy for shock, he was transferred to the operation theater for massive arterial bleeding from the wound. The left common carotid artery and internal jugular vein were exposed by extending the skin incision from the cervical wound along the anterior border of the left sternocleidomastoideus. The left common carotid artery and the internal jugular vein were simultaneously transected, and end-to-end anastomosis of the carotid artery was performed under the administration of 300 ml of Sendai Cocktail. The occlusion time of the left common carotid artery was approximately 50 minutes. Right hemiparesis and total aphasia did not change immediately after the surgery. The postsurgical CT scan showed an infarction in the posterior portion of the left middle and posterior cerebral arteries. However, after undergoing rehabilitation for a month, the patient could walk alone, and his aphasia improved. Many large series of penetrating injuries to the carotid artery were reported after World War II. Most casualties were younger males injured by gunshot. In middle cervical injury, the common carotid artery is the most vulnerable vessel, although other large vessels such as the external and internal carotid arteries as well as the internal jugular vein may be involved, often causing neurological deficits and shock.(ABSTRACT TRUNCATED AT 250 WORDS)

[A patient with gigantic heterotopic gray matter with epileptic seizures]

We report a patient with partial seizure and gigantic heterotopic gray matter. A 23-year-old young man was admitted to our hospital with complaints of frequent epileptic seizures and psychiatric symptoms. There was psychomotor delay in infancy. At the age of 4 years, afebrile convulsions appeared on several occasions. Seizures characterized by a lapse of consciousness started at the age of 13 years. He often stayed in a fantasy world and became very emotional at such time. Cranial CT demonstrated an irregularity in the wall of right lateral ventricle and disappearance of the posterior horn on the same side. This lesion, adjacent to that wall, had a signal intensity that was similar to that of the gray matter on each sequence in MRI. Histopathology of this lesion showed a number of large and small neurons. Therefore, heterotopic gray matter was diagnosed. MRI demonstrated wide cortices suggesting polymicrogyria in the right parietal lobe. Complex partial seizures with eye deviation to the left were recognized. Interictal EEG showed frequent high voltage spikes in the right temporal, fronto-temporal and parieto-occipital areas independently. Therefore, epileptic foci were thought to exist in or around those lesions.

Aneurysms arising from the proximal (A1) segment of the anterior cerebral artery. A study of 38 cases

This study reviews aneurysms of the proximal segment (A1) of the anterior cerebral artery in 38 patients (23 men and 15 women) and their surgical, angiographic, and clinical management. Thirty-seven aneurysms were saccular and one was fusiform. The incidence of A1 aneurysms among a total of 4295 aneurysm cases treated was 0.88%. Multiple aneurysms occurred in 17 patients (44.7%) of the 38 cases; in 10 (58.8%), there was bleeding from the A1 aneurysm. The aneurysms were classified into five categories according to the mode of origin of the aneurysm in relation to the A1 segment: in 21 cases, aneurysms originated from the junction of the A1 segment and a perforating artery; in eight, from the A1 segment directly; in six, from the proximal end of the A1 fenestration; and in two, from the junction of the A1 segment and the cortical branch. One patient had a fusiform aneurysm. Computerized tomography (CT) of these aneurysms revealed bleeding extending to the septum pellucidum similar to that of anterior communicating artery aneurysms. When performing radical surgery it is very important to recognize the characteristics of A1 aneurysms, including multiplicity, a high incidence of vascular anomalies (especially A1 fenestration), and their similarity to anterior communicating artery aneurysms on CT.

Acid cholesteryl ester hydrolase activity of mononuclear leukocytes in patients with non-insulin-dependent diabetes mellitus: studies before and after treatment of diabetes

The change of acid cholesteryl ester hydrolase activity in mononuclear leukocyte following treatment of diabetes mellitus was studied in 21 patients with non-insulin-dependent diabetes mellitus (NIDDM). Enzyme activity before treatment in the patients was significantly lower than that in 14 age-matched healthy subjects (1.20 +/- 0.15; mean +/- S.E. vs. 2.20 +/- 0.17 nmol/mg protein/h, P less than 0.01). Enzyme activity before treatment in the patients was significantly increased (P less than 0.05) after 4-8 weeks of treatment. However, enzyme activity of 1.43 +/- 0.14 nmol/mg protein/h observed after treatment in the patients was significantly lower (P less than 0.01) than that in the healthy subjects. There was a significant negative correlation between enzyme activity before treatment and the increase in enzyme activity following treatment (rs = -0.555, P less than 0.01, n = 21). These results indicate that low level of enzyme activity may be insufficiently improved by the treatment of diabetes, and the risk for the development of atherosclerosis as viewed from the enzyme activity may persist even after the treatment in NIDDM.

[Clinical analysis of cerebral infarction in children]

Six cases of cerebral occlusive disease in children were reported. The cerebral arterial occlusive disease had its onset at the age of less than 4 years, except for one case of a 9 year-old. The causes of occlusion were, trauma in two cases, infectious disease in one case, intraarterial myxoma in one case and an unknown reason in two cases. Initial symptoms were sudden onset of hemiplegia in 5 cases, and headache in one case. Angiography revealed stenosis of the main trunk of the middle cerebral artery, or of the anterior cerebral artery in 4 cases. Angiographical manifestations of stenosis in 4 cases were classified into two types, diffuse stenosis and localized stenosis. No stenotic changes were demonstrated in two cases, in which CT revealed a small low density area in the putamen. Follow up angiogram in three cases revealed improvement of stenosis. Though therapy in all cases was conservative, their prognosis is not so poor as had been considered. As the rate of recanalization in children was assumed to be high as compared with adult cases, it was considered that surgical revascularization in the acute stage had to be undergone very carefully.

10-year follow-up study of epilepsy with psychosis

Thirty-three cases of psychosis associated with epilepsy were followed in our clinic for 10 years. In 12 cases, the psychotic symptom appeared episodically and 9 of them had more than one relapse and 7 of them more than 2 relapses. Only 3 cases had no relapse. In 21 cases, the psychotic symptoms were continuous, lasting more than 2 years. In 8 of them, the symptoms were stable and remained unchanged but in 13 of them, the symptom showed exacerbation and partial remissions. In 11 cases, a decrease or discontinuation of antipsychotic drugs (mostly haloperidol) significantly provoked or aggravated the psychotic symptoms.

[Superoxide anion (O2-) production by polymorphonuclear leukocytes in insulin dependent diabetes mellitus (IDDM)]

The superoxide anion (O2-) production in polymorphonuclear leukocytes stimulated by phorbol myristate acetate in IDDM and non-insulin dependent diabetes mellitus (NIDDM) was determined by the method of Johnston et al, compared with that of each age matched controls. And the correlation between O2- production and hemoglobin (Hb) A1 and A1c value was investigated. The O2- production in IDDM was 24.4 +/- 7.4 (mean +/- SD, n mol per 4 X 10(5) cells) at 10 min. and 51.4 +/- 8.7 at 30 min., in NIDDM each 31.6 +/- 9.3, 60.2 +/- 14.4, and in controls each 40.5 +/- 4.2, 72.4 +/- 3.1. O2- production in IDDM was significantly lower than that in NIDDM (p less than 0.001 at 10 min. and p less than 0.01 30 min.) and controls (p less than 0.001 at 10 and 30 min.). O2- production at 10 and 30 min. possessed a negative correlation with Hba1 and A1c value (HbA1: p less than 0.01 at 10 min. p less than 0.05 at 30 min., HbA1c: p less than 0.01 at 10 and 30 min.). These findings suggest that impaired O2- production might be one of the factors accounting for depressed bactericidal activity of polymorphonuclear leukocytes in IDDM, and that a protracted hyperglycemia might shed some effect on O2- production.

[Delayed traumatic vasospasm: correlation between cerebral vasospasm and contusion]

The pathogenesis of delayed traumatic vasospasm is not yet fully understood. We present six cases of delayed traumatic symptomatic vasospasm along with CT scan and angiographic findings. The cases ranging in age from 16 to 78 years all had head injury caused by traffic accidents. The Glasgow coma scale on admission was 9 - 15 except in one severe case GCS 6. Initial CT scans were obtained on the day of injury in four patients and on the 2nd and 3rd days in the other two cases respectively. There was no distinct subarachnoid hemorrhage in the suprasellar cistern. Subarachnoid hemorrhage in the Sylvian cistern was observed with particular care in all patients. However the severity of subarachnoid hemorrhage was mild (isodensity or slight high density by CT) in 4 cases. Brain contusions on CT scan were observed in the temporal and/or frontal region of 5 of 6 patients. Ischemic symptoms occurred during the period between 5 and 13 days after head injury. The cerebral angiogram taken after the occurrence of these symptoms revealed spasms in all patients, the spasm being bilateral in 2 of them. Spasms were recognized on the main arteries at the base of the brain such as C1, M1, M2 and A1. In 5 cases, the cerebral contusion and the spasm were located on the same side. Angiographically the vasospasms lasted 2 to 5 weeks. The prognosis based on the Glasgow outcome scale was good recovery in 3 patients and moderate disability in one. Two elderly patients with bilateral spasms were in a vegetative state and severe disability, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)