[A case of water intoxication presenting as urinary retention in a psychotic patient]

A 43-year-old man, who had been treated for chronic schizophrenia, was admitted to our hospital with the chief complaint of urinary retention. His serum levels of sodium and osmotic value were low and serum creatine phosphokinase (CPK) was elevated to 2,624 mg/dl. He had been consuming about 9 liters of water a day for ten years. A diagnosis of water intoxication was made and treated successfully with water restriction and drip infusion. To our knowledge, this is the 23rd case of water intoxication with serum creatine phosphokinase elevation reported in the Japanese literature and this is the first case with the chief complaint of urinary retention.

Effectiveness of fibrin glue for preventing postoperative extradural fluid leakage

Cerebrospinal fluid (CSF) leakage through dural sutures after craniotomy increases the risk of complications such as persistent CSF fistulas, meningitis, and subcutaneous, graft bone, or epidural infections. The effectiveness of fibrin glue for preventing CSF leakage through dural closure was investigated in 183 patients who underwent frontotemporal craniotomy for unruptured aneurysm. Fibrin glue was used in 138 patients, but not in the other 45. Computed tomography was used to evaluate postoperative extradural fluid collection as a minimal volume of low-density area. Postoperative computed tomography demonstrated transient increases in extradural fluid collection in 55 patients. However, none of these patients received a second surgery for dural repair. Fluid collection occurred in 19 of 45 patients (42%) in whom fibrin glue was not used, and in 36 of 138 patients (26%) in whom fibrin glue was used. The fibrin sealant on the dural suture was a significant factor in reducing the incidence of the fluid leakage (p < 0.05, chi-square test). Fibrin glue is a useful surgical tool for the prevention of postoperative extradural fluid collection through the dural sutures.

Resection of a recurrent parasagittal meningioma with cortical vein anastomosis: technical note

BACKGROUND

Simpson Grade I resection of parasagittal meningiomas is not always feasible because of the involvement of the sagittal sinus and cortical veins. Complete resection requires reconstruction of the sagittal sinus and cortical veins. This report describes a surgical technique to preserve patency of the cortical veins.

CASE REPORT

A recurrent parasagittal meningioma completely occupied the superior sagittal sinus and encased several large cortical veins. The tumor in the sagittal sinus was totally resected and the roof of the sinus was sutured. To avoid thrombotic cortical vein occlusion, two cortical veins encased by the meningioma were anastomosed end-to-end, regardless of their flow directions. The postsurgical course was uneventful and patency of the anastomosed veins was confirmed by postoperative angiography.

CONCLUSIONS

End-to-end anastomosis of cortical veins was a useful surgical technique for radical resection of a parasagittal meningioma.

Hemifacial spasm caused by a hemangioma at the geniculate ganglion: case report

OBJECTIVE AND IMPORTANCE

Hemifacial spasm is rarely caused by facial nerve lesions in the temporal bone. Intratemporal facial nerve hemangiomas may initially present as facial spasm.

CLINICAL PRESENTATION

A 30-year-old woman developed right hemifacial spasm. Physicians observed slight weakness on the right side of her face, in addition to the hemifacial spasm, but routine radiological examinations did not detect any abnormal findings along the course of the facial nerve. Although the patient underwent neurovascular decompression, the spasm persisted postoperatively. Two years after surgery, the right facial palsy progressed. Concurrently, the hemifacial spasm diminished. High-resolution computed tomography demonstrated a small mass lesion expanding the cortex of the right petrosal bone involving the geniculate ganglion of the facial nerve.

INTERVENTION

The patient underwent a second craniotomy through a subtemporal extradural route, and the tumor was completely removed. A pathological examination demonstrated a cavernous hemangioma.

CONCLUSION

Routine radiological examinations may fail to detect small intratemporal facial nerve hemangiomas, particularly at the geniculate ganglion. Therefore, when physicians encounter atypical facial spasm, the intratemporal portion of the facial nerve should be carefully examined using high-resolution computed tomography.

Nitric oxide as a carcinogen: analysis by yeast functional assay of inactivating p53 mutations induced by nitric oxide

We have used a yeast p53 functional assay to study induction of mutations in the p53 tumor suppressor gene by nitric oxide and cytosine methylation. The yeast assay identifies only biologically important p53 mutations. p53 cDNA was treated with the nitric oxide donor sydnonimine, PCR-amplified and transfected into yeast. Sydnonimine produced a significant, dose-dependent increase in C:G-->A:T transversions. Many important p53 mutational hotspots are postulated to arise by deamination of methylCpG in tumors. We therefore examined nitric oxide induction of mutations in p53 cDNA methylated by PCR-mediated substitution of 5-methylcytosine for cytosine or by treatment with the SssI CpG methylase. Both methylation procedures increased the baseline mutation rate, and nitric oxide treatment produced a further increase in mutation yield. Sequence analysis showed that methylation alone led to C:G-->T:A transitions, whereas nitric oxide treatment simply produced more C:G-->A:T transversions. Thus the most important factor in C:G-->T:A transition at CpG sites identified in this experimental system is cytosine methylation, consistent with spontaneous conversion of 5-methylcytosine to thymine by deamination.

Surgical removal of a cavernous sinus chondroma

BACKGROUND

Chondromas at the base of the skull are most commonly found in the parasellar and sellar regions, and present varying degrees of involvement of the cavernous sinus. However, those confined mainly to the cavernous sinus are rare, and only a few reports show detailed radiological and surgical findings.

MATERIALS AND METHODS

This 40-year-old woman experienced sudden right orbital pain followed by right third and sixth cranial nerve palsies. Computerized tomography scan and magnetic resonance image depicted a well-circumscribed mass in the right cavernous sinus. A frontotemporal craniotomy with orbito-zygomatic osteotomy was used to approach this lesion intradurally. We drilled away the anterior clinoid process using a high-speed air drill extradurally, exposed the intrapetrous carotid artery, and dissected the right sylvian fissure from the distal, fully exposing the surface of the right cavernous sinus. The soft and grayish tumor was easily removed using sucker and tumor forceps; the venous bleeding from the sinus itself was easily controlled.

RESULTS

The tumor was successfully removed via a superior triangle. Intradural invasion of the tumor and heavy venous bleeding from the sinus were not observed. Histologically, the mass was diagnosed as a mature chondroma. The tumor was presumed to originate from the right posterior clinoid process. The lesion was totally removed, and postoperative right ophthalmoplegia had fully disappeared within 6 months after surgery.

CONCLUSION

Successful surgical attack of lesions in the cavernous sinus requires comprehensive and precise knowledge of the microsurgical anatomy and neuroradiology.

Management of primary intracranial germinomas: diagnostic surgery or radical resection?

Because intracranial germinomas are readily curable with radiation and chemotherapy or radiation therapy alone, the role of radical surgery has become debatable. This study assesses the optimum degree of surgical resection for intracranial germinomas. Twenty-nine patients who underwent surgery for germinoma were retrospectively analyzed (male/female ratio 27:2, median age 18 years). Among these 29 patients there were 10 solitary pineal, seven solitary neurohypophyseal/hypothalamic, and 12 multifocal or disseminated tumors. Biopsy samples were obtained in 16 patients (stereotactically in eight, transsphenoidally in four, and via frontotemporal craniotomy in four). Partial resection was attained in five patients (via a frontotemporal approach in three and occipitotranstentorially in two). Gross-total resection was achieved via an occipitotranstentorial route in eight patients with pineal masses. After surgery, 10 patients were treated with radiotherapy alone, and 19 received radiation and chemotherapy; complete remission was achieved in all 29 patients. The overall tumor-free survival rate was 100% at a median follow-up period of 42 months. There was no significant difference in outcome related to the extent of surgical resection. Postoperative neurological improvement was seen in only two patients, whereas transient postoperative complications, mainly upgaze palsy, were observed in six. One patient experienced a slight hemiparesis, bringing the surgical morbidity rate to 3% (one of 29). It is concluded that radical resection of intracranial germinomas offers no benefit over biopsy. The primary goal of surgery should be to obtain a sufficient volume of tumor tissue for histological examination. If there is strong evidence of germinoma on radiological studies, biopsy samples should be obtained. When a perioperative histological diagnosis of pure germinoma is made during craniotomy, no risk should be taken in continuing the resection.

Idiopathic intracranial hypertension in female homozygous twins

The authors report on female homozygous twins with idiopathic intracranial hypertension. At the age of 12 years, both twins simultaneously developed visual disturbances with photophobia. At the age of 19 years, an ophthalmological examination disclosed papilloedema in both their eyes. At the age of 22 years, a lumbar puncture showed raised CSF pressure over (200 mm H2O) in both twins. Their neurological and radiological examinations were extremely similar; both of them had severely impaired visual acuity and impaired visual field, bilateral optic nerve atrophy, intracranial hypertension, an enlarged and partial empty sella turcica, digital markings of the calvalium, and an enlarged frontal subarachnoid space. This is the first case report describing idiopathic intracranial hypertension occurring in homozygous twins.

Vanishing tumor of the temporalis muscle: repeated hemorrhage in an intramuscular venous hemangioma

We present a rare case of venous hemangioma in the temporalis muscle that repeatedly and spontaneously enlarged and disappeared over several months. MR imaging depicted multiple fluid-fluid levels in the tumor alongside characteristic findings of hemangioma, indicating that the peculiar course was due to hemorrhage and blood resorption within the tumor.

[Single stage excision for an intractable brain abscess and free rectus abdominis flap for reconstruction of the anterior skull base]

A case is presented of the frontal brain abscess following resection of squamous cell carcinoma of the maxillary sinus who had undergone reconstruction of the anterior skull base using a free rectus abdominis muscle flap. Local flap, ex. galeal flap, can be used for separating the cranial space from the paranasal sinuses and the nasopharynx, but it cannot provide reliable separation and protection of the brain from bacterial flora of the upper airway and it is too weak to support the brain in cases where orbital exenteration has been performed. The distant flaps such as the pectoralis major musculocutaneous flap, on the other hand, can provide a good alternative for reconstruction of the anterior skull base in such difficult cases, but frequently requires a secondary division of the pedicle. The free flap can circumvent such problems. We used the free rectus abdominis muscle flap and the postoperative course was uneventful. A bone graft was not necessary to reconstruct the anterior skull base.

Basilar invagination associated with an intercarotid paraganglioma--case report

A 24-year-old female presented with basilar invagination and kyphoscoliosis of the cervical spine associated with a large intercarotid paraganglioma. She had suffered from pharyngeal discomfort from the age of 9 years due to the tumor. The tumor had originated from the right carotid body and extended in the parapharyngeal space compressing the upper cervical spine. Presumably the slowly growing tumor had caused the kyphoscoliosis and disturbed osseous development of the occipito-atlanto-axial complex, resulting in anterior basilar invagination, hypoplasia of the clivus, and aplasia of the posterior arch of the atlas.

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.

Reappraisal of p53 mutations in human malignant astrocytic neoplasms by p53 functional assay: comparison with conventional structural analyses

We previously reported clonal expansion of p53 mutations in malignant astrocytic tumors detected with a yeast p53 functional assay that measures mutant p53 alleles quantitatively and loss of p53 transcriptional competence qualitatively (Tada et al., Int J Cancer 67:447-450, 1996). This method selectively detects inactivating mutations and is relatively insensitive to contamination of tumor samples with normal tissue. To determine whether the mutation frequency and spectrum detected in this way differ from those seen with conventional techniques, 54 malignant astrocytomas were tested with the yeast assay, and the abnormalities detected were characterized by DNA sequencing. Inactivating p53 mutations were found in 67% of anaplastic astrocytomas and 41% of glioblastomas. Overall, mutations were found in 48% of tumors, compared with only 29% in previous studies (P < 0.005), a difference that probably reflects the greater sensitivity of the yeast assay than of conventional techniques. The frequency of mutations in anaplastic astrocytomas (in our study plus published studies) was significantly higher than in glioblastomas (39% vs 29%; P < 0.05). This suggests that acquisition of p53 mutations is not rate limiting for progression to glioblastoma and that many glioblastomas develop by p53-independent pathways. Sequencing of mutant p53 cDNAs rescued from yeast showed that the mutation spectrum for functionally inactive mutants was nearly identical to the spectra from previous studies on structural mutants, indicating that transcriptional activity is the critical biological target of p53 mutation in malignant astrocytomas.

Full functional recovery after surgical repair of transected abducens nerve: case report

OBJECTIVE AND IMPORTANCE

Results of surgical repair of the injured abducens nerve are rarely reported in the literature. A full functional recovery of a completely resected abducens root may be exceptional. We describe a patient who obtained normal ocular alignment and binocular vision after surgical reconstruction of a transected abducens nerve.

CLINICAL PRESENTATION

A 56-year-old woman with a petroclival meningioma was presented. She underwent total removal of the tumor through a combined supra/infratentorial transpetrosal approach. The abducens nerve was tightly attenuated by the tumor and thickened dura. During dissection, the nerve was completely transected just behind the entrance to Dorello's canal.

INTERVENTION

The abducens nerve was the single root type and inevitably required surgical repair. To obtain a sufficient length of the distal stump for trimming, part of the petrosphenoidal ligament was cut and the superior border of the petrous bone was exposed. The proximal stump of the nerve was also trimmed to obtain healthy tissue, and reconstruction was performed with five 10-0 nylon sutures. Five months later, esodeviation began to improve. Nine months after the surgery, the patient did not complain of diplopia and an objective assessment reported normal ocular alignment and estimated binocular function as "excellent" according to Biglan's system. Overcorrection of abduction did not occur.

CONCLUSION

The result in our patient confirms the possibility of full functional recovery after surgical repair of a totally transected abducens nerve.

Analysis of long-term treatment of intracranial germinoma

PURPOSE

To determine an appropriate treatment policy for intracranial germinoma.

METHODS AND MATERIALS

From 1976 to 1992, 51 patients with germinoma (18 with pathologically verified germinoma and 33 diagnosed as having germinoma by neuroimagings) were treated by radiation therapy. Various radiation doses and treatment fields were used.

RESULTS

The 10-year cause-specific survival rate for pathologically verified and unverified germinoma was 100% and 96%, respectively. Relapses were noted in four patients, three of whom died from the disease. Two of the four patients with a tumor larger than 4 cm in gross diameter experienced relapse. Two relapses occurred in a nonirradiated spinal canal and two occurred in the irradiation area treated by 25 Gy in 10 fractions and 30 Gy in 20 fractions. No relapse was noted in patients in whom the whole ventricle field was determined precisely using three-dimensional treatment planning. Five patients who were followed at an outpatient clinic experienced significant late neurocognitive dysfunction, which set in after radiotherapy.

CONCLUSION

After pathological confirmation, 40 Gy whole-ventricle irradiation using precise three-dimensional treatment planning is appropriate as a standard treatment for most intracranial germinoma.

Homozygous p53 gene mutation in a radiation-induced glioblastoma 10 years after treatment for an intracranial germ cell tumor: case report

OBJECTIVE

Radiation-induced glioma is a rare but serious complication of radiotherapy. Underlying radiation-induced mutations in oncogenes or tumor suppressor genes have not previously been described.

CLINICAL PRESENTATION

A 16-year-old female patient developed a glioblastoma in the right frontal lobe 10 years after treatment of a suprasellar germ cell tumor with 50 Gy ionizing radiation. The glioblastoma was undetectable on a high-resolution magnetic resonance image obtained 3 months before diagnosis.

METHODS AND RESULTS

A p53 functional assay was used to examine the transcriptional competence of the p53 tumor suppressor gene. This assay scores the content of mutant p53 alleles in tumor and blood samples quantitatively as a percentage of red yeast colonies. The glioblastoma contained 95% mutant p53 alleles, whereas blood from the patient and her parents contained only normal background levels of red colonies. Sequencing revealed that the mutation in the tumor was a 3-base pair deletion affecting codons 238 and 239. Intragenic deletion within the p53 deoxyribonucleic acid binding domain is uncommon in sporadic tumors but would be entirely consistent with misrepair of a radiation-induced double-strand deoxyribonucleic acid break in this case.

CONCLUSION

This is the first case in which a causative underlying genetic event has been identified in a radiation-induced glioblastoma. We infer that mutation of one p53 allele occurred at the time of radiotherapy, and the sudden appearance of the tumor 10 years later occurred after loss of the remaining wild-type allele and/or other genetic alterations, such as chromosome 10 loss and epidermal growth factor receptor gene amplification.

Hypoglossal-facial nerve side-to-end anastomosis for preservation of hypoglossal function: results of delayed treatment with a new technique

This report describes a new surgical technique to improve the results of conventional hypoglossal-facial nerve anastomosis that does not necessitate the use of nerve grafts or hemihypoglossal nerve splitting. Using this technique, the mastoid process is partially resected to open the stylomastoid foramen and the descending portion of the facial nerve in the mastoid cavity is exposed by drilling to the level of the external genu and then sectioning its most proximal portion. The hypoglossal nerve beneath the internal jugular vein is exposed at the level of the axis and dissected as proximally as possible. One-half of the hypoglossal nerve is transected: use of less than one-half of the hypoglossal nerve is adequate for approximation to the distal stump of the atrophic facial nerve. The nerve endings, the proximally cut end of the hypoglossal nerve, and the distal stump of the facial nerve are approximated and anastomosed without tension. This technique was used in four patients with long-standing facial paralysis (greater than 24 months), and it provided satisfactory facial reanimation, with no evidence of hemitongue atrophy or dysfunction. Because it completely preserves glossal function, the hemihypoglossal-facial nerve anastomosis described here constitutes a successful approach in patients with long-standing facial paralysis who do not wish to have tongue function compromised.

Stereotactic irradiation without whole-brain irradiation for single brain metastasis

PURPOSE

The effectiveness of stereotactic irradiation (STI) alone without whole-brain irradiation (WBI) for a single metastatic brain tumor was analyzed retrospectively.

METHODS AND MATERIALS

Forty-four patients with this condition were treated using radiosurgery (RS) alone or fractionated stereotactic radiotherapy (FSR) without WBI.

RESULTS

The initial response rate was 92% and the overall local control rate was 84% (37 of 44 patients). A total of 39% (18 of 44) of patients experienced intracranial relapse outside the initial target area. Forty-eight percent (21 of 44) of patients required salvage treatment for intracranial relapse. All 7 patients who received WBI as salvage treatment required no further salvage treatment, but 5 of the 14 patients who received salvage STI without WBI required three to four treatments for brain metastasis. Late radiation damage was not seen with initial treatment but was observed with retreatment. The overall median survival time was 261 days, with a standard error of 64 days. Actuarial survival at 12 and 24 months was 34% and 9%, respectively. The actuarial survival rate was significantly affected by the existence of active extracranial disease (p = 0.041).

CONCLUSION

The high response rate and short treatment period of STI alone are advantageous in the treatment of single brain metastasis in patients with active extracranial disease with WBI reserved for relapse. Because of the low complication rate, STI alone may be also useful in patients with good prognosis, without extracranial disease.

Osteoregenerative lateral suboccipital craniectomy using fibrin glue

This report describes a simple technique of cranioplasty for suboccipital craniectomy and the results of a clinical study to assess the effects of fibrin glue on regeneration of the skull. Cranioplasty using a mixture of autologous bone chips and human allogenic fibrin glue was performed in 31 patients who received lateral suboccipital craniectomy. Long-term observations with three-dimensional CT showed satisfactory reconstruction of the mastoid-occipital bone plate in 25 patients (81%); among them, a nearly complete reconstruction of the occipital bone (plate) was found in 14 patients. Regeneration of the bone began 6 months after surgery on the inner surface, adjacent to the dura mater. In conclusion, the present technique provides a new simple method to restore an autologous bone plate in a cranial defect made by piecemeal craniectomy.

Clival chordoma presenting as acute esotropia due to bilateral abducens palsy

A case involving a 14-year-old girl having clival chordoma with symptoms of diplopia, acute esotropia, and bilateral abducens palsy is reported. Magnetic resonance imaging revealed a clival tumor invading the posterior edges of the bilateral cavernous sinuses. After removal of the tumor, no ocular manifestations were noted. The importance of acute esotropia as a sign indicating a possible brainstem mass is emphasized.

Receptor protein tyrosine kinase DDR is up-regulated by p53 protein

We have previously reported on radiation-induction of ptk-3 in rat astrocyte culture [Sakuma et al. (1995) Radiat. Res. 143, 1-7]. Ptk-3 was considered to be a rat version of human DDR (discoidin domain receptor). We cloned and analyzed genomic DNA of the DDR and its promoter region. We discovered that the promoter region contained a consensus sequence of the p53 tumor suppressor binding site. Adenovirus-mediated p53 transfection induced a high level of DDR mRNA in SAOS2 human osteosarcoma cells. These results indicate that DDR is up-regulated by the p53 protein.

Long-term evaluation of radiation-induced brain damage by serial magnetic resonance imaging

The long-term changes during late delayed radiation-induced brain damage were investigated by serial magnetic resonance (MR) imaging of eight patients over a mean follow-up period of 45 months after irradiation. The radiation damage appeared as an enhanced lesion on T1-weighted MR images with gadolinium-diethylenetriaminepenta-acetic acid (Gd-DTPA) at 3 to 30 months after radiotherapy (mean 12.8 months). In all patients, an abnormal high signal intensity area on T2-weighted imaging preceded the enhanced lesion. The volume and number of enhanced lesions continued to increase for 3 to 23 months (mean 10.3 months). The high signal intensity area on T2-weighted imaging simultaneously expanded. The lesions were subsequently stabilized, and in four long-term survivors, the Gd-DTPA-enhanced lesions then decreased in size, the intervals from onset to regression were 12, 13, 17, and 35 months (mean 19.3 months), respectively. However, two patients showed a relapse of the enhanced lesion with latent periods of 8 and 9 months, respectively. Finally, the radiation-damaged brain became atrophic including the high signal intensity area on T2-weighted images. Late delayed radiation-induced brain damage continues to progress for over a year and then regresses, but thereafter a relapse may occur.

Current diagnosis and treatment of central nervous system germ cell tumours

Central nervous system germ cell tumours can be cured with high quality posttreatment neuropsychological and endocrinological measures. In order to firmly establish a histological diagnosis, surgery is essential. Management should be planned precisely according to histological and biological malignancy and the extent of the disease. Patients with germinoma can be cured by preirradiation chemotherapy followed by reduced dose irradiation.