Surgical treatment of glossopharyngeal neuralgia as vascular compression syndrome via transcondylar fossa (supracondylar transjugular tubercle) approach

OBJECTIVE

These are the first reported cases in whom the transcondylar fossa approach was applied for the treatment of glossopharyngeal neuralgia (GPN) as a vascular compression syndrome.

CASES PRESENTATION

All three cases presented with severe paroxysmal pharyngeal pain which could not be controlled by medical treatment. The patients all underwent microvascular decompression surgery (MVD) via transcondylar fossa approach. The posterior inferior cerebellar artery or the anterior inferior cerebellar artery was clearly verified to be compressing the glossopharyngeal nerve and then was safely and completely moved and fixed to the dura mater by the sling retraction technique to effect decompression. No patient has since experienced any further pain or permanent neurological deficit after surgery. TECHNICAL ADVANTAGE: The transcondylar fossa approach is one of the lateral approaches which is different from the transcondylar approach. In this approach, the posterior part of the jugular tubercle is extradurally removed without injuring the atlanto-occipital joint. The entire course of the cisternal portion of the glossopharyngeal nerve can be sufficiently seen with gentle retraction of the cerebellar hemisphere, when using this approach.

CONCLUSION

This approach makes the MVD for GPN both effective and safe.

[Atelectasis of the right lower lobe in association with bronchiolitis obliterans organizing pneumonia]

A 58-year-old woman with underlying rheumatoid arthritis was admitted to the hospital because of a dry cough and the presence of an abnormal shadow in the right lower lung field. Consolidation and volume loss in the right lower lobe with air bronchogram were recognized on a chest tomogram. Bronchofiberscopic examination disclosed neither stenosis nor tumors in the large bronchi. Organizing pneumonia was recognized pathologically in transbronchial lung biopsy (TBLB) specimens. The volume of the right lower lobe decreased rapidly, and new infiltration shadows appeared in the right upper and middle lobes. Another bronchofiberscope examination revealed organizing pneumonia, and macrophage infiltrations were seen in the alveoli on histopathological examination of the TBLB specimens. The diagnosis of RA-associated BOOP was made on the basis of agreement of the expansion of the shadows on chest radiographs, the RA symptoms and the RA factor. The patient was treated with prednisolone, and the clinical course was satisfactory, with no recurrence. This case was of interest because BOOP inducing lobar cicatricial atelectasis is very rare.

Seroprevalence of antibodies to Chlamydia spp. in human immunodeficiency virus-infected subjects in Japan

To evaluate the seropositivity of Chlamydia spp. in human immunodeficiency virus (HIV)-infected subjects in Japan, Chlamydia-specific antibodies in sera collected from 106 HIV-infected subjects were measured by the microimmunofluorescence test. The prevalence of C. pneumoniae-specific IgA, C. trachomatis-specific IgG and IgA and mean titers were significantly higher in the homosexual and heterosexual HIV-infected subjects than in the hemophilic patients and HIV-negative controls. These data indicate that the higher C. pneumoniae and C. trachomatis seroprevalence among HIV-infected subjects is probably due to an HIV risk factor, such as promiscuous sexual behavior, rather than to HIV infection itself.

The missing fundamental phenomenon in temporal vision

Subjective flicker rates were measured for compound waveforms consisting of five harmonics without a fundamental component. It was found that observers perceived a rate at the fundamental frequency, although energy at this frequency was not included in the signals. In auditory pitch sensation this is called the missing fundamental phenomenon, and an analogous finding is known to occur in spatial vision. Moreover, observers perceived the flicker rates at the fundamental frequency even in the random-phase conditions, in which the period of the fundamental component is unclear in the real waveforms. The results indicate that the perceived flicker rates are not detected from the temporal waveforms per se. One possible mechanism for extracting such a periodicity in the signal is an auto-correlation function to the real temporal waveforms.

[Clinical analysis of patients with community-acquired pneumonia requiring hospitalization classified by age group]

We classified 1017 patients with community-acquired pneumonia requiring hospitalization experienced in Kawasaki Medical School Kawasaki Hospital during the past 15 years into five age groups (< or = 54 years old, 55-64 years old, 65-74 years old, 75-84 years old, > or = 85 years old). With particular emphasis on the elderly patients, we then compared the clinical and microbiological findings in the five groups. The results were as follows; (1) Half of patients in the over 85 years old group were bed-ridden. (2) The proportion receiving antibiotics before hospitalization decreased with age. (3) There were striking atypical pneumonic symptoms, such as dyspnea and consciousness disturbance in the two age groups over 75 years old. (4) Hypotension (shock) increased with age. (5) Markers of nutritional conditions, such as serum protein, albumin, cholinesterase, and hypoxia remarkably increased in the two age groups over 75 years old. (6) There were no significant differences in the isolation rate of etiological microorganisms. (7) The number of polymicrobial agents in the < or = 54 years old group was lower than that in the other age groups. (8) Mycoplasma pneumoniae was most significantly higher in < or = 54 years old group, Haemophilus influenzae in patients 55-64 years old, and Streptococcus pneumoniae in both 65-74 and 75-84 years old groups. (9) The isolation rate of MSSA, gram-negative bacilli such as Klebsiella pneumoniae, Pseudomonas aeruginosa, respiratory viruses increased with age. (10) The amount of sepsis increased with age. (11) The prognosis was poor in the two groups over 75 years old because the mortality rate (over 10%) was higher that for the other age groups.

Inverting papilloma of the sphenoid sinus: report of two cases

Two patients with sphenoid sinus inverting papilloma who were treated either by transcranial or sublabial trans-septal approach are reported. Inverting papillomas arising from the sphenoid sinus are exceedingly rare. The clinical and neuro-imaging features, as well as surgical treatment, for sphenoid sinus tumours are also briefly discussed.

[Increased intracranial pressure caused by obstruction of torcular herophili with hemangiopericytoma: a case report]

A 49-year-old male had experienced diplopia for half a year. The intracranial pressure was markedly elevated (450 mmH2O). Neuroimaging revealed a tumor incompletely occluding the torcular herophili and the bilateral transverse sinuses without cerebral or cerebellar compression by the tumor. Both cortical veins and cervical veins were enlarged, and the Sylvian vein and Rabbe's vein and the tentorial sinus were collateral vessels. Biopsy was performed and histologic examination proved hemangiopericytoma. The patient underwent Gamma-knife treatment and the tumor decreased in size 3 months after the treatment.

Transcerebellomedullary fissure approach with special reference to methods of dissecting the fissure

OBJECT

The purpose of the present study was to refine the transcerebellomedullary fissure approach to the fourth ventricle and to clarify the optimal method of dissecting the fissure to obtain an appropriate operative view without splitting the inferior vermis.

METHODS

The authors studied the microsurgical anatomy by using formalin-fixed specimens to determine the most appropriate method of dissecting the cerebellomedullary fissure. While dissecting the spaces around the tonsils and making incisions in the ventricle roof, the procedures used to expose each ventricle wall were studied. Based on their findings, the authors adopted the best approach for use in 19 cases of fourth ventricle tumor. The fissure was further separated into two slit spaces on each side: namely the uvulotonsillar and medullotonsillar spaces. The floor of the fissure was composed of the tela choroidea, inferior medullary velum, and lateral recess, which form the ventricle roof. In this approach, the authors first dissected the spaces around the tonsils and then incised the taenia with or without the posterior margin of the lateral recess. These precise dissections allowed for easy retraction of the tonsil(s) and uvula and provided a sufficient view of the ventricle wall such that the deep aqueductal region and the lateral region around the lateral recess could be seen without splitting the vermis. The dissecting method could be divided into three different types, including extensive (aqueduct), lateral wall, and lateral recess, depending on the location of the ventricle wall and the extent of surgical exposure required.

CONCLUSIONS

When the fissure is appropriately and completely opened, the approach provides a sufficient operative view without splitting the vermis. Two key principles of this opening method are sufficient dissection of the spaces around the tonsil(s) and an incision of the appropriate portions of the ventricle roof. The taenia(e) with or without the posterior margin of the lateral recess(es) should be incised.

[Brain stem hemorrhage associated with venous angioma: report of two cases]

The incidence of hemorrhage associated with venous angioma has been considered to be rare. We here report two cases of brain stem venous angioma which also showed brain stem hemorrhage. Case 1; a 15-year-old female had experienced weakness in the left upper extremity 8 months prior to admission. She developed dysfunction of the left cranial nerves, and magnetic resonance imaging (MRI) showed a huge enlarging hematoma in the pons. Cerebral angiography showed venous angioma penetrating through the pons. Evacuation of the hematoma was performed through the fourth ventricle and many small vessels were found in the hematoma. Although all symptoms were partially resolved after the operation, a re-hemorrhage occurred 1 month after the operation. Case 2; a 50-year-old man had suddenly developed headache and vertigo several days prior to admission. Computed tomography (CT) and MRI showed a small hematoma in the lesion with venous angioma adjacent to the hematoma. All symptoms gradually resolved with conservative therapy.

[Two cases of B cell lymphoma associated with hemophagocytic syndrome]

B cell lymphoma-associated hemophagocytic syndrome (B-LAHS) is clinically characterized by hepatosplenomegaly and bone marrow invasion without lymphadenopathy and skin lesions. Several cases of B-LAHS have been reported to demonstrate histopathologic findings of intravascular lymphomatosis (IVL), which in Western countries is characterized by a high rate of skin involvement and, rarely, bone marrow involvement and hemophagocytosis. Here we describe two interesting cases of B-LAHS. One patient was a 52-year-old woman whose bone marrow showed proliferation of large CD20-positive cells and hemophagocytosis at presentation. Combination chemotherapy was not effective, and the patient died of progressive disease. At autopsy, the lymphoma cells showed extravascular proliferation in many organs such as the bone marrow and liver, whereas in the adrenal glands, the lymphoma cells showed intravascular proliferation. The other patient was a 50-year-old man who had swellings of the bilateral kidneys and adrenal glands at presentation. Skin involvement by large lymphoma cells, a rare complication of B-LAHS, was observed. At autopsy, there was no evidence of IVL. Both of these patients showed high fever and cytopenia, and the disease took an aggressive clinical course, as in other reported cases of B-LAHS.

[Small epidermoid induced trigeminal neuralgia unrecognized by conventional CT and MRI for over 25 years]

A 65-year-old woman had been conservatively treated as idiopathic trigeminal neuralgia for over 25 years, because conventional computed tomography (CT) and magnetic resonance imaging(MRI) showed no abnormality in the cerebello-pontine(CP) angle cistern. She received a detailed MRI by constructive interference in steady state and diffusion weighted image(DWI) sequences. Those sequences on MRI well demonstrated a epidermoid tumor in the CP angle cistern, and the removal of the tumor completely resolved the neuralgia. Since a small epidermoid in the CP angle cistern seems to be unrecognized by conventional CT and MRI, detailed evaluation by DWI sequence, which has been widespread recently, is required for patients with trigeminal neuralgia.

Serum KL-6 as a possible marker for amiodarone-induced pulmonary toxicity

Amiodarone is a useful drug for the treatment of life-threatening cardiac arrhythmias. However, amiodarone can induced pulmonary toxicity (APT) and may cause life-threatening lung damage. APT can be difficult to diagnose, but early diagnosis is important. Here, in a 51-year-old man with APT, the high serum KL-6 level was correlated with the severity of symptoms and chest X-ray findings, and it was inversely correlated with PaO2 and diffusion capacity for carbon monoxide levels. The findings suggest that the serum KL-6 level may be increased in APT and that therefore it's the determination of serum KL-6 may provide a useful indicator and/or monitoring marker of APT. KL-6 is believed to be produced and secreted by type II pneumocytes. Typical pathological findings of APT include proliferation of type II pneumocytes which may produce KL-6, and result in increased serum KL-6 levels.

[Desensitization therapy for allergic reactions of antituberculous drugs--evaluation of desensitization therapy according to the guideline of the Japanese Society for Tuberculosis]

We prospectively evaluated the effectiveness of desensitization therapy for cases showing side-effects to antituberculous drugs (Isoniazid and Rifampicin) according to the guideline proposed by the Treatment Committee of the Japanese Society for Tuberculosis. Nineteen patients (23-88 years old, male 9, female 10) who had experienced adverse effects after receiving antituberculous drugs and underwent desensitization therapy between August 1998 and March 2000 were studied. Underlying diseases were 14 cases of pulmonary tuberculosis, 2 cases of cervical tuberculous lymphadenitis, 1 case of pulmonary atypical mycobacteriosis, 1 case of pulmonary tuberculosis and tuberculous pleuritis, 1 case of pulmonary tuberculosis and tuberculous lymphadenitis. The regimens of treatment for tuberculosis were INH + RFP + EB in 8 cases, INH + RFP + EB + PZA in 7 cases, INH + RFP + SM in 2 cases, INH + RFP + SM + PZA in 1 case, and INH + RFP in 1 case. Adverse reactions were 8 cases of eruption, 7 cases of drug fever, 3 cases of drug fever and eruption, and 1 case of drug fever and cervical lymphadenopathy. The causative drugs suggested from DLST or the clinical course were RFP in 17 cases and INH in 8 cases. The clinical effect of desensitization therapy for these antituberculous drugs was good in 14 out of the 17 cases (82%) for RFP, and in 6 out of 8 cases (75%) for INH. The effectiveness rate of the present desensitization therapy according to the guideline of the Japanese Society for Tuberculosis was almost equal to that of previous desensitization therapy, and the clinical results were almost same in present and previous studies despite the different methods of administration of the antituberculous drugs.

[Nonmyeloablative stem cell transplantation with low-dose total body irradiation (200 cGy) for a 55-year-old woman with acute lymphoblastic leukemia]

We describe a 55-year-old woman with acute lymphoblastic leukemia (ALL) in the first remission who underwent nonmyeloablative stem cell transplantation with conditioning consisting of low-dose total body irradiation and postgrafting cyclosporine and mycophenolate mofetil. Myelosuppression was mild, but on day 28 her bone marrow showed 8.8% lymphoblasts. We withdrew the cyclosporine, but the patient developed grade 2 acute GVHD and eosinophilia. The proportion of bone marrow lymphoblasts decreased transiently to 1.0% on day 40, but later increased again and the patient died on day 85. Application of this approach to patients with ALL needs to be examined on a large scale.

Correlation between proton magnetic resonance spectroscopic lactate measurements and vascular reactivity in chronic occlusive cerebrovascular disease: a comparison with positron emission tomography

The purpose of this study is to investigate the correlation between lactate levels and cerebral vascular reactivity (VR) in regions outside an area of chronic cerebral infarction. Multivoxel proton magnetic resonance spectroscopy ((1)H-MRS) and positron emission tomography (PET) were performed in 11 patients who suffered chronic cerebral infarction. Of these 11 patients, 4 were examined before and after bypass surgery. Two regions-of-interests (ROIs) were placed outside the area of chronic infarction. One ROI was placed within a control region on the contralateral side. A lactate peak area was obtained in all ROIs. An N-acetyl aspartate (NAA) peak area was obtained in the ROI within the control region. The ratio of the lactate peak area and NAA peak area (Lct/NAA) was calculated for normalization of the lactate level, and was found to be 0.13 +/- 0. 10 (range, 0 to 0.43). The VR was recorded at 13.3 +/- 20.7% (range, - 44.3 to 68.9%), utilizing PET and administering acetazolamide. A significant negative correlation was observed between the Lct/NAA ratio and VR (r = - 0.709, p < 0.0001). These results suggest that lactate levels and VR are closely related in regions outside areas of chronic cerebral infarction.

[Relationship between cardiac natriuretic peptide (ANP/BNP) and fluid intake in patients with subarachnoid hemorrhage]

Several authors described elevated natriuretic peptides, atrial natriuretic peptide(ANP) and brain natriuretic peptide (BNP), in patients with subarachnoid hemorrhage(SAH), which were account for inappropriate antidiuretic hormone(SIADH) or cerebral salt wasting syndrome(CSW). Although the secretion of natriuretic peptide depends on the total blood volume, central venous pressure, and cardiac output volume, the volume of fluid intake in patients with SAH had not been taken in consideration in previous report. We here examined the relationship between fluid intake and the natriuretic peptides in two cases without cardiac failure. ANP elevated 2 or 3 days after SAH and remained in normal range for 2 weeks. BNP elevated when the volume of fluid intake was increased, and BNP did not elevate during the periods with lower fluid intake. Several authors proposed the possibility of iatrogenic factor in natriuresis after SAH and these results supported this opinion.

Early mutation of precore (A1896) region prior to core promoter region mutation leads to decrease of HBV replication and remission of hepatic inflammation

To evaluate the relationship between mutations and clinical courses, we investigated precore (preC) and core promoter (CP) mutations and serum HBV DNA levels in HBe-antibody-positive HBV carriers. Fifty-six asymptomatic carriers (ASC), 29 patients with chronic hepatitis who showed normal ALT levels for more than two years (CH-ASC), 31 patients with chronic hepatitis (CH), and 32 patients with hepatocellular carcinoma (HCC) were studied. Almost all patients (99.2%) had mutations in either CP or preC. Mutation only in preC (A1896) was present in 52.2% with ASC, 25.0% with CH-ASC, 16.1% with CH, and 8.0% with HCC, and was significantly higher in ASC (P < 0.01). The patients with only preC mutation showed low HBV DNA levels in each clinical stage. The mutation of preC (A1896) prior to the mutation of CP might control the replication of HBV, which leads to the remission of hepatitis.

Recurrent trigeminal neuralgia after microvascular decompression using an interposing technique. Teflon felt adhesion and the sling retraction technique

The causes of recurrence after microvascular decompression for trigeminal neuralgia and the results of re-operations were studied in 6 cases. Eighty-two patients with trigeminal neuralgia were operated on through microvascular decompression using the technique of interposing Teflon felt between the offending artery and the pons and/or nerve. Recurrence occurred in 14 cases (17.1%) and re-operations were carried out in 6 severe cases at which time the sling retraction technique was used. At the second operation, the adhesion of the interposed Teflon felt was found at the trigeminal nerve in all cases and the adhesions were the main cause of recurrence. The Teflon felt was dissected from the nerve, and the sling of the Teflon felt adhering to the offending arteries was fixed to the tentorium in order to transpose the arteries and avoid re-adhesion. All cases resulted in an excellent relief from pain and experienced no pain for at least 2 years. The intra-operative findings of our cases indicated that the microvascular decompression using the interposing technique may result in adhesion of the prosthesis to the nerve and thus eventually lead to recurrence. Our surgical experience also suggests that such recurrent cases should be re-operated on using the sling retraction technique instead of the interposing technique, even for the first microvascular decompression procedure.