Surgical treatment of middle cerebral artery aneurysms

The authors report their experience with the surgical therapy of middle cerebral artery (MCA) aneurysms in 413 cases, and describe their technique. After the M1 portion of the MCA is identified, the Sylvian fissure is opened. During the administration of 20% mannitol, temporary occluding clips are applied to the feeding and draining vessels of the aneurysm. The aneurysm is freed from all surrounding tissue, and the aneurysm neck is treated by ligation, clipping, or wrapping. Analysis of surgical results in 91 cases operated on after the surgical approach had become standardized indicates that more than 94% of patients have returned to useful social lives by the time of follow-up evaluation. Twenty-four percent of these patients were operated on within 48 hours after subarachnoid hemorrhage.

[Surgical treatment of middle cerebral artery aneurysms]

A review of 413 cases of middle cerebral artery aneurysms out of the means of 1621 cases which were operated upon by one of the authors (J. Suzuki), is made with regard to their surgical management. At operation, the patient is placed in the supine position with the head fixed neutral and chin slightly up. Small craniotomy is performed by means of a small semi-circular skin incision just behind the hair line. After exposure of the internal carotid artery, the arachnoid overlying the Sylvian fissure is cut distally in order to expose the middle cerebral artery. The most important principle for aneurysm surgery is to secure the afferent artery prior to aneurysm exposure. In our approach, the M1 portion runs horizontally so that we can secure the parent artery after evacuation of liquor at the chiasma and then dissect the aneurysm. We usually put the temporary clips on the afferent and efferent arteries of aneurysm, that is the M1 and M2's during dissection of the aneurysm. In order to prolong the time of temporary arterial occlusion, 20% mannitol solution is administered intravenously just prior to dural incision under normotensive and normothermic anesthesia. Under such condition, it is possible to occlude the middle cerebral artery for 40 minutes. On the treatment of aneurysm, it is important to expose the whole aneurysm. If only neck portion is exposed and treated, kinking or stenosis of the parent artery can occur due to adhesion, and a second aneurysm or small artery hidden behind can easily overlooked. Therefore, exposure of the entire aneurysm is necessary. Subsequently, ligation should be carried out, then neck clipping performed.(ABSTRACT TRUNCATED AT 250 WORDS)

[Chemiluminescence on hypoxic brain--the 1st report: relation between free radical reaction and energy metabolism]

To explore the possibility that cerebral ischemia or cerebral hypoxia may initiate a series of free radical reactions of brain tissue lipid constituents, we measured sequential change of chemiluminescence and energy metabolites during brain hypoxia in rat. The hypoxic brain was induced by arterial hypoxemia (PaO2 17-22 mmHg) with normocapnia (PaCO2 28-38 mmHg) and normotension (MABP 100-140 mmHg). 4% O2-96% N2 mixed gas was used as the replacement for obtaining lowered PaO2. We made another attempt to analyze chemiluminescence spectra on purpose of luminous mechanism investigation. No peroxidation occurred in prehypoxic state since there were no photon counts, however, chemiluminescence began to rise up in hypoxic state and remained high value in posthypoxic early state. Namely in hypoxic state, 3-min period showed 231 counts/10 sec X g and 5-min period showed 154 counts/10 sec X g. In posthypoxic state, 5-min period showed 217 counts/10 sec X g and 30-min period showed a similar decrease as prehypoxic state. The chemiluminescence spectroanalysis showed five peaks at 480 nm, 520-530 nm, 570 nm, 620-640 nm, 700 nm in wavelength. As to sequential changes of energy metabolism, hypoxia caused marked brain lactic acidosis, increase in ADP, pyruvate and a fall in glucose. However, all metabolites recovered at 30-min period in posthypoxic state, which suggests this was reversible brain hypoxia. A transition of chemiluminescence and energy metabolites suggests the occurrence of free radical reaction in hypoxic and posthypoxic brain. The spectroanalysis reveals the luminous mechanism as follows 1 delta g # 1 delta g----2(3)O(2) + h nu.

[A total removal case of cavernous angioma at the lateral wall of the third ventricle with interhemispheric trans-lamina terminalis approach]

A case of cavernous angioma at the lateral wall of the third ventricle which was totally removed with interhemispheric trans-lamina terminalis approach is reported. A 40-year-old male had a slowly progressive onset of partial diabetes insipidus and headache with no neurological deficit . CT scan revealed a high density area at anterior third ventricle. The tumor was diagnosed ectopic pinealoma because of CT findings and clinical symptoms. Irradiation and chemotherapy ( RAFP therapy) was performed to this lesion. After two months, his clinical symptoms disappeared. CT scan showed decrease of the density of the region at this point. He was discharged with no symptom. After a half year, he suddenly complained of right homonymous hemianopsia with headache. CT scan showed that the high density area became larger to left posterior than that of half year before. Left carotid angiogram showed no mass lesion and no abnormal vessel. Operation was performed with interhemispheric trans-lamina terminalis approach using bifrontal craniotomy. Operative findings revealed that the tumor situated at the lateral wall of the third ventricle, had rough surface with reddish colour, and old and fresh blood clots inside the tumor. The tumor was carefully dissected without brain damage and was totally removed. The histological findings was compatible with cavernous angioma. Post-operative CT scan showed no high density area. He was discharged with no neurological deficit without right homonymous hemianopsia. Cavernous angioma of anterior third ventricle is very rare.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical treatment of intracranial arteriovenous malformation

The surgical indication and techniques of intracranial arteriovenous malformations are discussed, on the basis of 203 experiences with AVMs. A special key point in our surgical techniques is described as follows. The feeding arteries of the AVM--or the main artery at the base of the brain, which is the original source of the feeding artery--are identified and prepared, and then temporary clips are placed on these arteries to produce vascular occlusion prior to the dissection of the AVM itself. During these procedures, 20% of mannitol should be administered to prolong the permissible time of cerebral artery occlusion. The administration method of mannitol is described in detail including dose and time schedule. The new prolongation method of temporary occlusion time, for which mannitol with fluorochemicals permits longer occlusion time, is also introduced.

[Long term survival of holoprosencephaly with shunting procedure (author's transl)]

A long survived case of holoprosencephaly with hydrocephalus has been infrequently reported in the literature. One such case were presented on this report. This male baby by cesarean section because of his large head circumferenced 45 cm. He was admitted to our clinic diagnosed as congenital hydrocephalus at the third day from birth. On admission the circumference of his head was measured 49 cm, but other external malformations were not noticed. Right transaxillary carotid angiogram showed anterior cerebral artery appeared like azygos anterior cerebral artery. Absence of falx and fornix were suspected pneumoventriculography and transillumination of the head. Finally he was diagnosed as holoprosencephaly accompanied with hydrocephalus by computed tomography. Ventriculo-peritoneal shunt was performed at the 22nd day of his life. On follow-up after discharge, mental and motor development was not so poor. He was able to speak a few of simple words one year after discharge. At present 4 years and 6 months after discharge, he can do simple conversation and walk with assistance. Repeated computed tomography shows the frontal cerebral mantle is thickening in 36 mm at present. Good resulted case of holoprosencephaly as presented here could not be found in the literature. The pathogenesis and treatment were also discussed here.

[Subdural effusion following radical surgery for chiasmal region tumors in children--report of 4 cases (author's transl)]

Four cases of subdural effusion following radical surgery for the chiasmal region tumors in childhood were presented in this report. Three out of four cases were craniopharyngioma and the remaining one was optic glioma. The pathogenetic mechanisms of this disorder were explained probably and at least partly by a change from internal to external hydrocephalus or craniocerebral disproportion due to cerebral atrophy in two of the four cases and unclear in the remaining two cases. In all four cases meningitis did not supervene postoperatively. The subdural effusion may be divided into two types according to symptomatology, i.e., "serious type" which presents with severe symptoms and "mild-type" which is virtually asymptomatic. The serious type required immediate surgical procedure, such as continuous subdural drainage and subduroperitoneal shunt, while the mild type should be carefully monitored for the course of subdural effusion by CT scan.

[A canine model of complete ischemic brain regulated with perfusion method (author's transl)]

A model of complete ischemic brain regulated with a perfusion method in dogs was produced by interrupting the main arteries at the base of the brain and perfusing the arterial blood from the femoral artery of the dog to the lt. hemisphere through a tube cannulated into the rt. M.C.A. retrogradely. The cerebral blood flow in the lt. hemisphere is regulated by the infused blood volume which can be regulated with a pump. Hyperemic brain, normal brain, incomplete ischemic brain and complete ischemic brain can be produced in the entire lt. hemisphere at will in all dogs. Recirculation is also possible by means of the regulation of blood flow after various degrees of ischemia. This model also allows for the study of the various effects of drugs on the ischemic brain and research on the sequential pathological and chemical changes without individual differences among the dogs. This model should be valuable for investigation of not only ischemia but also cerebral metabolism, cerebral pharmacology and cerebral blood circulation.

[Transdural anastomosis in moyamoya disease--vault moyamoy (author's transl)]

Transdural anastomosis in Moyamoya disease, which we have named as "Vault Moyamoya", is reported. It seems that these vault moyamoya vessels are apt to be developed at certain fixed positions; 9 definite places in children cases 6 in adults. Main feeding arteries of each vault moyamoya are dural arteries. In addition to them, the blood flow from STA and OA is found. The incidence of vault moyamoya at each position shows similar tendency both in children and adults cases. Vault moyamoya are developed more frequently around the base of the brain near the carotid fork, where occlusion exists. Less moyamoya are formed as the position is farther from the carotid fork. In children, the incidence of vault moyamoya seems to coincide with the phases of basal moyamoya. It is not clarified yet whether the adults vault moyamoya are straightly inherited from children vault moyamoya. Blood flow from vault moyamoya to the brain cannot be ignored. When STA-MCA anastomosis is applied to moyamoya cases, we had better take the degree of development and positions of vault moyamoya into consideration, because we have to cut STA and MMA in the procedure.

An analysis of follow-up results of 1000 intracranial saccular aneurysms with definitive surgical treatment

The authors report a follow-up review of 1000 cases of intracranial definitive surgery for saccular aneurysms. The prognosis for such surgical cases is discussed. Postoperative results at least 6 months after discharge from the hospital were analyzed in 876 (93.3%) of the 939 surviving patients. The longest follow-up period was 14 years and 5 months, with an average of 3 years and 7 months. At the time of discharge, there were 543 excellent results, 186 good, 117 fair, 93 poor, and 61 deaths. The chief findings were as follows: 1) Most of the patients determined as "excellent" or "good" at discharge were able to return to normal life; most of the deaths or instances of worsened condition found in the follow-up study were due to new lesions. 2) Fully 62% of the cases determined as "fair" at discharge were found in an improved state at the follow-up study, having returned to normal life. 3) Only 19% of cases determined as "poor" at discharge had improved to the point where a return to normal life was possible, the majority having died or remaining in poor condition.

Distribution of intracranial aneurysm

The 1,080 cases of intracranial saccular aneurysms, which were seen at our clinic during the period from June 1961 to September 1975, were subjected to the analysis on the location of the aneurysms, age distribution and sex incidence.

Intracranial saccular aneurysms--surgical results of 1,000 consecutive cases

The results of our surgical treatment of 1,000 patients with intracranial saccular aneurysm were analyzed with special consideration for age, site of aneurysm, preoperative condition and operative timing. The results on discharge were as follows: 543 cases, excellent; 186, good; 117, fair; 93, poor; and 61, dead. About three-fourths of the cases except for 23 cases of vertebrobasilar aneurysm showed either excellent or good result. The mortality rate became worse with aging. The results fairly correlated with the preoperative grades by Hunt and Hess (1968), but the cases of Grade Ia were unexpectedly worse. The timing of operation influenced the mortality rate; especially, the cases operated within 3 to 7 days following the last subarachnoid hemorrhage bore poor results. Follow-up studies revealed that excellent and good cases increased and poor cases decreased. The mortality rate for each year decreased annually to 2% in 1975. This improvement may be attributed to the advancement in the operative management with supplementary procedures and in the treatment for cerebral angiospasms and general condition.

[Brain metastases from primary cardiac myxosarcoma--report of a case (author's transl)]

A very rare case of a myxosarcoma with metastases to the brain is reported. A 33-year-old female was admitted to our hospital because of lassitude, fever, slight left hemiparesis, headache and other signs of intracranial hypertension and cardiac symptoms such as dyspnea and palpitation. She had the cardiac symptoms once 14 years before, which reappeared and rapidly aggravated two months before the admission. Cerebral angiography revealed a mass in the right temporal lobe and physical and laboratory examinations revealed mitral value failure and hyperthyroidism. On the next day, March 19, 1976, a grossly cystic 60 gm tumor was totally removed which was largely imbedded in the subcortex of the right temporal lobe. The symptoms except for the cardiac symptoms and disseminated intravascular coagulopathy rapidly improved, but headache and left hemiparesis returned 13 days postoperatively. She died suddenly 18 days after the operation due to acute cardiac failure. Autopsy revealed two separate hard and solid tumors both attached to the mitral valve and occupied the whole left atrium and another metastasis to the frontal lobe which had not been diagnosed before the death. Microscopic examinations including electronmicroscopic study established the diagnosis of myxosarcoma in all the four tumors.

[Medulloblastoma with intractable ascites treated by carboquone--a complication of a ventriculoperitoneal shunt (author's transl)]

Although complication occasionally occur in the use of ventriculoperitoneal shunts (VP-shunt), the occurrence of intractable ascites and extracranial metastasis through the shunt are uncommon. Recently intractable ascites occurred in a two years old girl in whom a left VP-shunt had been placed before four month for obstructive hydrocephalus secondary to medulloblastoma. Paracentesis was performed with recovery of clear, straw-colored fluid with a specific gravity of 1012, a protein content of 0.3 gm/L and many of mononuclear cell on microscopic examination. Liver-scan and enzyme profile gave normal results. During 3 weeks, 6 times paracentesis were performed and total volumes of ascites were 3850 ml. At 5 and 6 times paracentesis, Carboquone 1 mg was injected into peritoneal cavity and 0.1 mg into ventricle cavity through flashing device. After these injection, intractable ascites were cured, no metastasis can be seen in peritoneal cavity when died 4 month later. No precise explanation can be offered for occurrence of this intractable ascites. It is said that chronic irritation of the visceral and parietal peritoneum or sub-clinical peritonitis may cause peritoneal malabsorption. In our case, antitumor agent was very effective, so this treatment will be recommended to try for intractable ascites.

[Pituitary apoplexy of giant pituitary adenoma--case report (author's transl)]

Pituitary apoplexy, characterized by sudden onset or acute progression of signs and symptoms of pituitary adenoma, is rare yet well-known. One such case is presented with clinical course, neuroradiological findings and autopsy. A 53-year-old female complained of sudden onset of severe headache, and rapidly deteriorated in the level of consciousness. Five days later, she became comatose and was admitted to National Sendai Hospital. Plain skull films and carotid angiograms revealed a remarkably large mass in the pituitary fossa. Death came ten hours after admission. Autopsy revealed a giant tumor (10 X 5 X 7.5 cm) destroying the sella turcica and protruding toward both the nasopharyngeal cavity and the hypothalamic region. Microscopically, diagnosis was made as chromophobe adenoma with fresh hemorrhage in the tumor.

[Electromyographic studies on the effect of transection-anastomosis of goat abomasum (author's transl)]

The four bipolar electrods were chronically sutured on the serosa of pylorus of four female goasts (29-36 kg in weight): from oral, electrod No. 1, No. 2, No. 3, No. 4. Electromyograms of abomasum were recorded before and after transection-end-to-end anastomosis of pylorus (between No. 2 and No. 3 electrods). The results are summarized as follows: 1. Before transection - anastomosis, anti-peristaltic discharge was not found in the pylorus. 2. After the anastomosis, prolonged discharge interval of peristalses and anti-peristaltic discharges occured in the upper part of the anastomosis (No. 1 and 2). 3. In the lower part of the anastomosis (No. 3 and 4), prolonged discharge interval of peristalses occured in all four goats, but anti-peristalic discharges were found in three goats. 4. Propagation velocity of anti-peristalic discharges became more faster than that of normo-peristalses.