Leukotriene C4contents, synthase and catabolic activity in human meningiomas

Leukotriene has been proposed as a factor of tumour induced brain oedema. Independently of its size, meningioma occasionally shows various extents of peritumoural oedema. We investigated LTC4 tissue contents, LTC4 catabolic and synthetic activity in 12 human meningiomas and their correlation with peritumoural oedema was studied. LTC4 contents were varied from 0.01 to 8.21 pg/mg tissue. When LTA4, an unstable expoxide intermediate was incubated with tumour homogenate, LTC4 was rapidly synthesized. However, LTC4 levels generated by incubating LTA4 with each homogenate were much different in each case. Degradation of LTC4 to LTD4, LTE4, and other polar materials was also rapid by incubation with tumour homogenates. Approximately 70% of added LTC4 was transformed to LTD4, LTE4 nor 6-trans LTB4 diastereoisomers during 30 min incubation at 37 degrees C. The results suggested that there were significant LTC4 tissue contents and LTC4 synthetic and catabolic activity in meningiomas. Oedema index ranged from 1.0 (no peritumoural oedema) to 67.5. No significant correlation, however, was observed not only between the LTC4 tissue contents and LTC4 synthetic or catabolic activities but also between each of these three parameters and peritumoural oedema. Thus, these results do not support a significant correlation of sulfidopeptide LTs with oedema formation in meningioma patients. Since leukotrienes are extremely unstable compounds, LTC4 tissue contents should be carefully discussed along with a consideration of rapid LTC4 synthesis and catabolism. Further role of leukotrienes in meningioma tissue should be studied.

Diversity and phylogeny of mitochondrial DNA isolated from mithun Bos frontalis located in Bhutan

We sequenced the 16S rRNA gene in mitochondrial DNA to characterize mithun located in Bhutan and to increase our understanding of its origin. We compared mithun with yak, European cattle, Bhutanese zebu and Indian zebu. Sequencing revealed low nucleotide diversity within the mithun population and their phylogenetic proximity to gaur. A close relationship between Bhutanese mithun and gaur was confirmed by an additional comparison with wild gaur specimens from three locations in Bhutan. Direct domestication of mithun from gaur was supported, while maternal contribution from the cattle lineage during domestication was not supported.

Increased lymphocyte trafficking to colonic microvessels is dependent on MAdCAM-1 and C-C chemokine mLARC/CCL20 in DSS-induced mice colitis

Although enhanced lymphocyte trafficking is associated with colitis formation, little information about its regulation is available. The aim of this study was to examine how the murine liver and activation-regulated chemokine (mLARC/CCL20) contributes to lymphocyte recruitment in concert with vascular adhesion molecules in murine chronic experimental colitis. T and B lymphocytes isolated from the spleen were fluorescence-labelled and administered to recipient mice. Lymphocyte adhesion to microvessels of the colonic mucosa and submucosa was observed with an intravital microscope. To induce colitis, the mice received two cycles of treatment with 2% dextran sodium sulphate (DSS). In some of the experiments antibodies against the adhesion molecules or anti-mLARC/CCL20 were administered, or CC chemokine receptor 6 (CCR6) of the lymphocytes was desensitized with excess amounts of mLARC/CCL20. Significant increases in T and B cell adhesion to the microvessels of the DSS-treated mucosa and submucosa were observed. In chronic colitis, the accumulation of lymphocytes was significantly inhibited by anti-mucosal addressin cell adhesion molecule (MAdCAM)-1 mAb, but not by anti-vascular cell adhesion molecule-1. In DSS-treated colonic tissue, the expression of mLARC/CCL20 was significantly increased, the blocking of mLARC/CCL20 by monoclonal antibody or the desensitization of CCR6 with mLARC/CCL20 significantly attenuated the DSS-induced T and B cell accumulation. However, the combination of blocking CCR6 with MAdCAM-1 did not further inhibit these accumulations. These results suggest that in chronic DSS-induced colitis, both MAdCAM-1 and mLARC/CCL20 may play important roles in T and B lymphocyte adhesion in the inflamed colon under flow conditions.

Neuroendoscopic third ventriculostomy in a patient with occluded foramen of Monro: a case report

We treated recurrent hydrocephalus in a previously shunted patient by neuroendoscopic third ventriculostomy. A tear was noted in the septum pellucidum. As the foramen of Monro was found to be occluded, we first fenestrated the floor of the lateral ventricle and then performed third ventriculostomy through the fenestration. A tough membrane believed to be Liliequist's membrane isolated the space immediately beneath floor of the third ventricle from the cistern below. Cerebrospinal fluid pulsation appeared after fenestration of this membrane. These obstructions presumably resulted from congenital and/or inflammatory causes. In cases such as this, successful neuroendoscopic third ventriculostomy presents a challenge to surgical judgment.

Evolution of malignant cerebellar astrocytoma at the site of a treated medulloblastoma: report of two cases

The authors report two unusual cases in which a malignant astrocytoma developed at the site of the excision of an earlier medulloblastoma. While the precise etiology of these astrocytic tumours was unproven, theories of the origins of the second tumours, particularly in relation to the basic nature of medulloblastomas, are discussed.

Multiple palisading granulomas in the scalp of an infant: a case report

BACKGROUND

We describe an unusual lesion that represents an uncommon but important element in the differential diagnosis of subcutaneous scalp nodules in a child.

CASE DESCRIPTION

A 1-year-old boy presented with two clusters of subcutaneous scalp nodules. The lesions increased in size and number. Computed tomography showed no changes in underlying bone. Findings on magnetic resonance imaging were nonspecific. Serologic and clinical evaluation showed no evidence of rheumatic disease. Complete excision of the nodules, together with adjacent fascia and galea, was performed. Histopathologic examination showed the lesions to be palisading granulomas; given the absence of rheumatic disease, these represented deep granuloma annulare, a benign condition. No recurrence has been observed in our patient.

CONCLUSION

While we chose total excision because of preoperative concerns about a possible malignant tumor, some other authors have suggested that surgery be limited to confirmatory biopsy when a benign lesion such as palisading granuloma is strongly suspected.

[Clinical trial of bradykinin-enhancing chemotherapy for a recurrent malignant glioma: a case report]

Patients with malignant glioma undergo a combined treatment with surgical resection, radiotherapy, and chemotherapy. Although those treatments usually show some restraining effects on the tumor, a relapse occurs in most of the patients within a few years. We have investigated the feasibility and safety of intra-arterial chemotherapy for malignant brain tumors by enhancing vascular permeability using intra-arterial bradykinin infusion. In 2001, The Committee of Ethics in Kyushu University approved our clinical trial of the bradykinin-enhancing chemotherapy for recurrent malignant gliomas. We here report the first case of our clinical trial. A 31-year-old man, who had undergone surgical resection followed by chemotherapy and irradiation for malignant progression of the left frontal astrocytoma over a period of 2 years, had a relapse of the tumor in the bilateral frontal lobes. After obtaining informed consent, bradykinin and carboplatin were infused through a microcatheter at the left A1 portion under general anesthesia. By dose escalation of bradykinin, the enhanced lesion in the bilateral frontal lobes diminished on magnetic resonance imaging after 3 trials with 3-week intervals, regardless of new lesions outside of the treated area. No neurological or physiological complication including myelosuppression was noted. Bradykinin-enhancing chemotherapy appeared to be effective and safe for malignant glioma. Because it was able to increase drug delivery to the tumor, it was possible to reduce the size of the dose of chemotherapeutic agent, which resulted in minimum complication.

Primary Ki-1 lymphoma in the central nervous system

Large cell anaplastic malignant lymphoma with Ki-1 (CD30) antigen is a new entity among human non-Hodgkin's malignant lymphomas according Updated Kiel Classification and is also a very rare subtype in primary central nervous system (CNS) malignant lymphomas. The precise clinical characteristics and the significance of Ki-1 antigen have yet to be clarified. The authors herein report a case of Ki-1 positive primary T-cell CNS malignant lymphoma. A 49-year-old man presented with multiple mass lesions in the brain on MRI. Immunohistochemical investigations of biopsy specimens from the superior medullary velum revealed a large cell anaplastic T-cell lymphoma positive for Ki-1 antigen. After administering extensive chemo-radiotherapy, the patient has survived for more than 42 months after the onset of symptoms.

Mobile intracranial oily substances from a ruptured teratoma

A patient with a ruptured intracranial teratoma is presented. The distinctive imaging and neuroendoscopic findings of mobile fatty or oily globules in the subarachnoid or ventricular space are described. Fat suppression magnetic resonance imaging (MRI) and MRI performed with the patient prone was helpful in distinguishing tumour tissue from floating oil.

[Twin-twin transfusion syndrome and intraventricular hemorrhage followed by hydrocephalus: report of two cases]

We report 2 infants who were born as one of monochorial twins. Both of them had been suffering from twin-twin transfusion syndrome(TTTS) as a donor fetus. Case 1 was delivered by caesarean section at the 28th week of pregnancy. On day 0, intraventricular hemorrhage(IVH) occurred from the right subependymal germinal matrix layer, and progressive ventricular enlargement was followed. Case 2 was delivered by the caesarean section at the 31st week of pregnancy. On day 9, he developed IVH from the choroid plexus at the trigone of the left lateral ventricle, and progressive enlargement of the inferior and posterior horns, trigone and posterior part of the body of the left lateral ventricle was followed. IVH in patients with TTTS usually occur in recipient infant but it can also occur in donor infant as in our cases. Pathophysiology of central nervous system damages associated with TTTS is variable and complicated.

Resolving obstructive hydrocephalus from AVM

Obstructive hydrocephalus with deterioration of consciousness from a ruptured arteriovenous malformation (AVM) requires urgent decompression, but also vigilance during the preoperative stage in case of rare spontaneous resolution.

Vascular endothelial growth factor in chronic subdural haematomas

OBJECTIVE

To elucidate molecular aspects of the mechanisms of expansion of chronic subdural haematomas (CSH), we examined the expression of two representative angiogenic factors, vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) in CSH.

METHODS

We quantified VEGF and bFGF in haematoma fluid and serum of 20 patients with CSH using an enzyme-linked immunosorbent assay. Mean concentrations of VEGF in the haematoma fluid (10277 pg/ml) and in serum, (355 pg/ml) were much greater than those of bFGF (haematoma, 3.04 pg/ml; serum, 4.74 pg/ml). Surgical specimens, including dura and the outer membrane of the CSH were analysed by in situ hybridisation to detect VEGF mRNA. Macrophages and vascular endothelial cells in the outer membrane over expressed VEGF mRNA.

CONCLUSIONS

Enhanced production of VEGF by macrophages and vascular endothelial cells in the outer membrane is thought to be pathogenetically important in CSH.

A lateral ventricular gliosarcoma arising in an ependymoma

OBJECTIVE

We describe a 29-year-old man with gliosarcoma in the lateral ventricle.

CASE

The patient presented with headache and impairment of consciousness. Computed tomography and magnetic resonance imaging localized the tumor to the right lateral ventricle and showed heterogeneous enhancement with administration of contrast agents. The tumor was partially removed via a transcallosal approach. Histologic examination disclosed gliosarcoma arising by malignant transformation of an ependymoma. POST-OPERATIVE COURSE: The patient died of tumor progression 78 days after admission, despite intensive radiotherapy and chemotherapy.

Pneumonitis induced by ou-gon (scullcap)

A 53-year-old Japanese man with recurrent interstitial pneumonia was referred to us. The patient had taken a traditional herb medicine, otsu-ji-to, before the onset of pneumonia. A provocation test for each herbal ingredient contained in otsu-ji-to revealed that the pneumonitis had been induced by ou-gon (scullcap). Lymphocytosis with the CD8+ T-cell subset predominance was found in the bronchoalveolar lavage fluid and lymphocytic alveolitis was noted in the transbronchial lung biopsy specimen after the provocation test. Ou-gon, or scullcap, should be included in the list of drugs with definite causal association with pneumonitis.

Surgery on a saccular vertebral artery-posterior inferior cerebellar artery aneurysm via the transcondylar fossa (supracondylar transjugular tubercle) approach or the transcondylar approach: surgical results and indications for using two different lateral skull base approaches

OBJECT

The authors report on the surgical results they achieved in caring for patients with vertebral artery-posterior inferior cerebellar artery (VA-PICA) saccular aneurysms that were treated via either the transcondylar fossa (supracondylar transjugular tubercle) approach or the transcondylar approach. In this report they clarify the characteristics of and differences between these two lateral skull base approaches. They also present the techniques they used in performing the transcondylar fossa approach, especially the maneuver used to remove the jugular tubercle extradurally without injuring the atlantooccipital joint.

METHODS

Eight patients underwent surgery for VA-PICA saccular aneurysms (six ruptured and two unruptured ones) during which one of the two approaches was performed. Clinical data including neurological and radiological findings and reports of the operative procedures were analyzed. The Glasgow Outcome Scale was used to estimate the activities of daily living experienced by the patients. In all cases the aneurysm was successfully clipped and no permanent neurological deficits remained, except for one case of severe vasospasm. In seven of the eight patients, the transcondylar fossa approach provided a sufficient operative field for clipping the aneurysm without difficulty. In the remaining patient, in whom the aneurysm was located at the midline on the clivus at the level of the hypoglossal canal, the aneurysm could not be found by using the transcondylar fossa approach; thus, the route was changed to the transcondylar approach, and clipping was performed below the hypoglossal nerve rootlets.

CONCLUSIONS

Both approaches offer excellent visualization and a wide working field, with ready access to the lesion. This remarkably reduces the risk of development of postoperative deficits. These approaches should be used properly; the transcondylar fossa approach is indicated for aneurysms located above the hypoglossal canal and the transcondylar approach is indicated for those located below it.

[Surgery for acoustic neurinoma treated by gamma-knife radiosurgery: a case report]

A 52-year-old woman had a history of left hearing loss for 5 years. An acoustic neurinoma with 3.2 cm in diameter was diagnosed and treated with gamma-knife radiosurgery (19 Gy of marginal dose) 1 year and 4 months ago. She developed headache, nausea, and visual disturbance 1 month prior to admission. Slight left facial palsy appeared after radiosurgery. Magnetic resonance imaging demonstrated the tumor with central necrosis in the left cerebellopontine angle cistern, increasing in size to 3.5 cm in diameter, and hydrocephalus. Tumor removal was performed incompletely, because of the fibrous appearance of the tumor and severe adherence with the surrounding cerebellar tissue. Facial palsy did not worsen after surgery. Since the hydrocephalus was not resolved, a right ventriculo-peritoneal shunt was inserted. The clinical course in this case suggests that tumor removal followed by radiosurgery was an approximately effective treatment for large acoustic neurinoma.

Late occurrence of diffuse cerebral swelling after intracerebral hemorrhage in a patient with the HELLP syndrome--Case report

Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome can occur at any time in the course of pregnancy and is associated with many complications including fatal stroke. A 37-year-old female presented with HELLP syndrome causing an intracerebral hematoma, which was treated by evacuation and mild hypothermia. Unexpected diffuse cerebral swelling occurred on the 15th day of the initially favorable postoperative course. Considerable impairment of consciousness persisted despite conservative therapy. Serial computed tomographic findings indicated delayed cerebral vasospasm as the cause of the swelling. Particularly careful management is required even beyond the first 2 weeks for patients with stroke as a complication of HELLP syndrome.

[A case showing effective radiotherapy for a radiation-induced glioblastoma]

Radiation-induced glioblastoma is usually resistant to all treatments. We report a case with radiation-induced glioblastoma, in which radiotherapy was remarkably effective. A 14-year-old female with a history of acute lymphoblastic leukemia, at the age of 7, underwent 15 Gy of radiotherapy to the whole brain. She was admitted to our department due to the development of headache and nausea. Magnetic resonance imaging showed an irregularly enhanced mass in the left frontal lobe. Partial removal of the mass was performed and histological examination showed it to be glioblastoma with a high MIB-1 index. The patient underwent 40 Gy of local radiotherapy and chemotherapy with ACNU and Interferon-beta for 2 years. The residual tumor disappeared after the radiotherapy, and her status is still "complete remission", 29 months after the onset.

Neuroendoscopic treatment of cystic craniopharyngioma in the third ventricle

The third ventricle is a relatively uncommon location for craniopharyngiomas. Generally, craniotomy has been considered the procedure of choice in such cases. We describe a girl in whom a cystic third ventricular craniopharyngioma was successfully treated by evacuation of the cyst contents via a flexible neuroendoscope and precise placement of an Ommaya reservoir catheter within the tumor.

[Acute hepatitis B virus after chemotherapy for a case with germinoma]

A 28-year old man with HCG-producing germinoma had undergone chemotherapy and radiotherapy. On admission for the fifth session of maintenance chemotherapy, he was found to be positive for hepatitis B (HB)s antigen, but negative for HBs antibody. HBs antigen had been negative during previous admissions. Since liver function was normal, the patient underwent chemotherapy. During myelosuppression after chemotherapy, liver dysfunction developed and acute HB was diagnosed. He fortunately showed seroconversion 2 months after onset. Serum immunological examinations are required for patients receiving chemotherapy.

Efficacy of single-bolus vs. frequent low-dose treatment with nitrosourea in experimental gliomas

BACKGROUND

Malignant glioma remains a fatal disease. Continuous or frequent low-dose (FLD) chemotherapy with nitrosoureas reportedly causes fewer side-effects than single-bolus therapy without decreasing the antitumour effects.

MATERIALS AND METHODS

To study the effect of FLD treatment with nimustine (ACNU) in rats with glioma, we intracerebrally inoculated with C6 glioma cells. We began the ACNU treatment 5 or 8 days later (total dose, 25 or 40 mg/kg) i.p. as either one bolus or smaller doses spread over 5 days week.

RESULTS

At a total dose of 25 mg/kg beginning at day 8, survival duration did not differ between untreated controls and the FLD group, while the bolus significantly prolonged survival; the FLD group showed some improvement beyond control survival at 40 mg/kg (each p <0.001). Beginning treatment after 5 rather than 8 days prolonged survival somewhat further.

CONCLUSION

FLD treatment with ACNU is less effective against experimental glioma in rats than bolus treatment.

[Primary thalamic hemorrhage penetrating to the lateral ventricle in an infant with abnormal protein S(protein S-Tokushima)]

We experienced a 3 months infant with thalamic hemorrhage penetrating to lateral ventricle with abnormal Protein S. Although the coagulation factor and fibrinogenolysis factors were evaluated, there were no remarkable abnormal laboratory data except for slightly decline of Protein S. The DNA analysis was performed for Protein S, and a missense mutation(A to G transmission) was found, which was resulting in Lys-155 to Glu. The total Protein S antigen was normal level, but co-factor activity for activated Protein C was declined. That mutation is named Protein S-Tokushima, and the patient who has abnormal Protein S tends to suffer recurrent coagulopathy. In our patient, it was interesting that any thrombotic disease had not occurred, but cerebral hemorrhage had occurred.

[Educational level of patients with germ cell tumor radiated in childhood]

In order to estimate the influence of radiotherapy on the intellectual development of children with brain tumor, we investigated the educational level of 21 patients with germ cell tumor who had undergone radiotherapy. They were divided into three groups in accordance with their age at the time of radiation; under school age group (under 6 years of age), elementary school age group (from 7 to 12 years of age), and junior high and high school age group (from 13 to 18 years of age). There were 2 cases in the under school age group, one of them graduated from high school and the other is presently a junior high school student. There were 5 cases in the elementary school age group. 3 of these graduated from university, 1 is presently a university student and 1 is a high school student. There were 14 cases in the junior high and high school age group. 2 of these are university students, 7 graduated from high school, 1 is presently a junior high school student, and 4 died because of tumor progression. The mean period of hospitalization of the patients who have been admitted to university was 63.0 days, and that of patients who have not been admitted university was 135 days. There is a statistical difference (p < 0.05). It could be concluded that the period of hospitalization rather than radiotherapy seemed to influence the educational status of children with brain tumor.

[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.

A simple method to estimate the secretion of saliva from minor salivary glands using iodine-starch reaction

OBJECTIVE/HYPOTHESIS

This study was undertaken to detect the faculty of secretion of saliva from minor salivary glands by analyzing a color reaction on a test tape containing iodine and starch that was applied on the lower lip.

STUDY DESIGN

A study involving 63 patients with oral dryness, 7 patients with Sjogren syndrome, and 70 healthy individuals was performed.

METHODS

A test tape (1 x 1 cm) containing iodine and starch was set on the mucosal area anterior to the labia frenulum for 30 seconds. Because the number of blue spots was considered to correspond to the number of ostia of the salivary gland on the lower lip that was examined, the number of blue spots occurring as a reaction of iodine and starch on the test tape was counted and was compared among three groups. In addition, the relationship between the histopathological findings and the number of spots was analyzed.

RESULTS

The average number of spots in the patients with oral dryness (4.52+/-3.18 [mean +/- SD]) was lower than that in healthy individuals (9.49+/-2.52, P <.01), and that in the patients with Sjögren syndrome (2.14+/-1.35) was the lowest among all groups in the study. Moreover, this reduction in the number of spots in those patients was accompanied by histopathological changes of the minor salivary glands.

CONCLUSION

These findings suggest that this simple, noninvasive method can be successfully used for the estimation of the faculty of secretion of saliva from the minor salivary glands.

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.

Fluid loading in rats increases serum brain natriuretic peptide concentration

Hyponatremia after subarachnoid hemorrhage has been linked to high plasma concentration of atrial natriuretic peptide and brain natriuretic peptide. Volume expansion therapy to prevent symptomatic vasospasm, such as intensive hypertensive and hypervoremic therapy, may alter systemic concentration of these peptides. We therefore examine brain natriuretic peptide secretion in rats in response to acute volume expansion, infusing to 10 ml of saline over 1 h. In the 10 ml group, brain natriuretic peptide concentrations showed a significant increase from pre-infusion concentrations 1 h after initiation of infusion, but had begun to fall 1 h later. We suspect that high plasma concentration of brain natriuretic peptide after subarachnoid hemorrhage is partly caused by hypervoremic therapy.

[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.

[A case of effective urgent irradiation therapy for metastatic spine tumor]

A 74-year-old man noticed weakness in bilateral lower limbs 2 months prior to admission. The weakness had rapidly progressed and he could not stand by himself on admission. All thoracic vertebral bodies showed mosaic pattern on T 2 weighted-image. At Th 10 and Th 11, two enhanced masses compressed spinal cord posteriorly. Basal-serum tumor markers, such as LDH, ALP, total-acid phosphatase and prostatic acid phosphatase were elevated, metastatic spine tumor from prostatic carcinoma was suspected. Biopsy specimen from its prostate revealed low differentiated adenocarcinoma. Because sphincter dysfunction progressed rapidly after admission, we started 3 Gy/day irradiation within 24 hr from its appearance targeting both Th 10 to L 1 vertebral bodies and the prostate in total 30 Gy. The clinical symptoms started to resolve immediately, and the disappearance completely within 7 months. This case illustrated that urgent irradiation was effective for broad metastatic spinal tumor with rapidly progressive neurological deficits.

[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.

Primary choroid plexus carcinoma producing carbohydrate antigen 19-9

An autopsy case of primary choroid plexus adenocarcinoma arising in a 40-year-old female, who was associated with a high serum level of a carbohydrate antigen 19-9 (CA19-9), is herein presented. After a subtotal removal of a tumor in the left lateral ventricle, the serum level of CA19-9 decreased rapidly, and immunohistochemical examinations of tumor tissue specimens obtained at surgery revealed intense reactivity for CA19-9. The present case may be the first example in which a primary choroid plexus carcinoma was shown to produce CA19-9.

[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.

Successful neuroendoscopic third ventriculostomy for hydrocephalus and syringomyelia associated with fourth ventricle outlet obstruction. Case report

The authors report the use of neuroendoscopic third ventriculostomy to treat successfully both hydrocephalus and syringomyelia associated with fourth ventricle outlet obstruction. A 27-year-old woman presented with dizziness, headache, and nausea. Magnetic resonance (MR) imaging demonstrated dilation of all ventricles, downward displacement of the third ventricular floor, obliteration of the retrocerebellar cerebrospinal fluid (CSF) space, funnellike enlargement of the entrance of the central canal in the fourth ventricle, and syringomyelia involving mainly the cervical spinal cord. Cine-MR imaging indicated patency of the aqueduct and an absent CSF flow signal in the area of the cistema magna, which indicated obstruction of the outlets of the fourth ventricle. Although results of radioisotope cisternography indicated failure of CSF absorption, neuroendoscopic third ventriculostomy completely resolved all symptoms as well as the ventricular and spinal cord abnormalities evident on MR images. Neuroendoscopic third ventriculostomy is an important option for treating hydrocephalus in patients with fourth ventricle outlet obstruction.

[Usefulness of ultrasonography in a case of spontaneous carotid-cavernous fistula: a case report]

Since spontaneous carotid-cavernous fistula (CCF) is a dural arterio-venous fistula at the cavernous sinus, which is different from traumatic CCF and CCF associated with a ruptured aneurysm at the cavernous internal carotid artery, cerebral angiography is required in order to differentiate these condition. We here report a case of spontaneous CCF, in which a result of ultrasonographic evaluation of cervical arteries well corresponded with that of cerebral angiography. Ultrasonography showed increased blood flow and decreased pulsatility index in the ipsilateral external carotid artery, contralateral internal and external arteries, and these values in all arteries resolved within normal range after the interventional embolization. Ultrasonography is less invasive examination and can be easily performed even in outpatients for observation of spontaneous CCF.

[T-cell lymphoproliferative disorder involving the central nervous system in two cases]

Lymphoproliferative disorder (LPD) sometimes occurs in immunosuppressive patients. B-cell proliferation is predominantly seen in patients with LPD and T-cell proliferation is rare. We here report two patients with T-cell LPD involving the central nervous system (CNS). A 7-year-old boy developed increased intracranial pressure and computed tomography showed a ring-enhanced mass lesion in the right frontal lobe. A 10-year-old boy developed gait disturbance and magnetic resonance imaging showed a non-enhanced lesion in the left parietal lobe. Radiological findings could not differentiate CNS-LPD from other intracranial diseases. Only histologic examination could diagnose LPD in both cases, and Epstein-Barr virus associated RNA was found in the infiltrated T-cell of the latter case. Although chemotherapy with antitumor agents was effective for remission of LPD in both cases, both patients died 3 years after their operations. As CNS-LPD shows rapid progression and frequently results in fatality, this disease requires immediate histologic diagnosis followed by extensive chemotherapy.

Hemorrhagic subdural effusion complicating an endoscopic III ventriculostomy

Subdural effusion, a common postoperative complication of extracranial shunting for hydrocephalus, is usually caused by excessive drainage of cerebrospinal fluid. Subdural effusion is thought to occur less frequently after a neuroendoscopic III ventriculostomy, and no reported cases have been symptomatic. We encountered a symptomatic subdural effusion with a component of hemorrhage 5 days after the latter procedure was performed to treat massive hydrocephalus in a 2-year-old boy.

[Medulloblastoma with neuronal differentiation: a report of five cases]

This report presents a retrospective analysis of 5 patients who were treated for cerebellar medulloblastoma with neuronal differentiation. Four males and 1 female ranged in age from 6 months to 9 years at the time of diagnosis. Total removal of the tumor was achieved in 3 patients, and partial removal in 2. While these tumors were composed of small cells and had regions resembling desmoplastic medulloblastoma, they in part showed neuronal characteristics which included parallel row or linear array arrangements of tumor cells in an eosinophilic fibrillary matrix. Postoperatively, 3 patients received craniospinal radiation therapy, one received local radiation to the primary site, and the remaining one received only systemic chemotherapy. During the follow-up period of 3.8-25.2 years, 4 patients have been in continuous remission with mild to moderate neurological deficits, while the remaining one died 3.9 years after surgery. The clinical and anatomic pathological features of medulloblastomas with neuronal differentiation are reviewed while the therapeutic problems associated with these tumors are also discussed.

A comparative study of apoptosis and proliferation in germinoma and glioblastoma

Intracranial germinoma has a relatively good prognosis when treated with radiotherapy and chemotherapy, whereas glioblastoma has a poor prognosis irrespective of these treatments. Cell proliferation and cell death are opposing processes in tumor growth, with tumor progression reflecting the balance between proliferating and apoptotic cells. We investigated cell proliferation and cell death using MIB-1 staining and nick-end labeling in 13 germinomas in comparison with 11 glioblastomas. Expression of BAX and Bcl-2, which regulate apoptosis, were studied by immunohistochemistry. Although germinomas showed strong MIB-1 immunostaining similar to that seen in glioblastomas, germinomas included significantly more apoptotic cells. The ratio of apoptotic ratio to MIB-1 labeling index for germinomas was 72.9 +/- 36.9 (mean +/- SD), a higher, statistically significant ratio as compared with glioblastomas (14.5 +/- 11.2; P < 0.01). Furthermore, germinomas showed greater expression of BAX than did glioblastomas, while the expression of Bcl-2 was weak in both tumor types. A comparison of these apoptotic-related proteins showed that immunoreactivity for BAX was relatively higher in germinomas than in glioblastomas (P < 0.01), corresponding well to numerous apoptotic cells identified in germinoma tissues. These findings may account for the prognostic difference between germinoma and glioblastoma in the face of a similar proliferation potential according to MIB-1 immunostaining. The balance between cell proliferation and death should be considered when predicting outcomes in patients with intracranial tumors.

High incidence of hyponatremia in patients with ruptured anterior communicating artery aneurysms

We studied the incidence and timing of hyponatremia (Na < 135 mEq l-1) after subarachnoid hemorrhage (SAH) with special reference to ruptured anterior communicating artery (A-com) aneurysms. Hunt and Kosnik (HK) grading, symptomatic vasospasm in A-com aneurysm, and hydrocephalus were analyzed for connections to hyponatremia in 55 patients with ruptured A-com aneurysms, 65 with ruptured internal cerebral artery (ICA) aneurysms, and 49 with ruptured middle cerebral artery (MCA) aneurysms. Hyponatremia occurred in 28 (51%) of 55 patients with A-com aneurysms and in nine (18%) of 49 patients with MCA aneurysms. Severe hyponatremia (Na < 130 mEq l-1) occurred in 16 patients (29%) in the A-com group, four patients (6%) in the ICA group, and three patients (6%) in the MCA group. The A-com aneurysm group had a significantly higher incidence of mild hyponatremia (p < 0.01) and severe hyponatremia (p < 0.001) than other groups. Among A-com cases, hyponatremia occurred significantly more often in HK grade III and IV cases (p < 0.05), in cases with vasospasm (p < 0.001), and in cases with hydrocephalus (p < 0.01). Respective days of onset for symptomatic vasospasm and for hyponatremia were day 7.6 +/- 4.4 and day 10.6 +/- 5.8 following SAH, representing a 3-day delay for hyponatremia (p < 0.05). In most patients hyponatremia resolved within 28 days following SAH. Hyponatremia occurred more often with A-com aneurysms, possibly because of vasospasm around the A-com or hydrocephalus causing hypothalamic dysfunction. Since hypervolemic therapy can cause hyponatremia, particularly careful observation is required during such therapy in patients with A-com aneurysm.

Normal diffusion-weighted imaging in cerebral air embolism complicating angiography

We report a case of cerebral air embolism resulting from accidental air infection during cerebral angiography. A 60-year-old man was accidentally injected with air via the left subclavian artery. Angiography demonstrated air within the basilar artery. The patient showed signs of posterior circulation ischaemia (confusion, blindness, gaze palsy and hemiparesis). However, MRI, including diffusion-weighted imaging, showed no abnormality 4 h later. The patient was treated with hyperbaric oxygen within 5 h of the embolism. All symptoms and signs resolved completely within a week.

Neuroendoscopic biopsy of tectal glioma: a case report

OBJECTIVE AND IMPORTANCE

A type of intrinsic dorsal midbrain glioma known as benign tectal glioma can cause obstructive hydrocephalus. Because of its slow progress and relatively good prognosis, initial treatment should be cerebrospinal fluid diversion and biopsy.

CLINICAL PRESENTATION

We report a 24-year-old man with obstructive hydrocephalus from a tectal glioma, who was admitted to the hospital for malfunction of a shunt placed 16 years previously.

INTERVENTION

Magnetic resonance imaging demonstrated enlargement of the dorsal midbrain associated with increased signal intensity on T2-weighted images and fluid attenuation inversion recovery (FLAIR) images. No enhancement occurred with contrast administration. We performed a neuroendoscopic third ventriculostomy and biopsy of the tumor. Histologic examination of the specimen obtained disclosed a low-grade astrocytoma. No postoperative neurologic complications occurred.

CONCLUSION

FLAIR images were superior to T2-weighted images in demonstrating abnormal intensity in the dorsal midbrain. Neuroendoscopy confirmed a yellowish tumor inferior to the posterior commissure occluding the entrance of the aqueduct, an observation useful in planning biopsy of the lesion. As the tumor apparently had existed for a number of years, the case supports the notion that the prognosis associated with these tumors is good.

Cerebellar neuroblastoma in an infant

A cerebellar neoplasm in an 8-month-old boy is reported. While this tumour was composed of small cells and had regions resembling desmoplastic medulloblastoma, it showed ultrastructural neuronal characteristics including bundles of microtubules in the cell processes, numerous synaptic vesicles, and occasional abortive or complete synapses. These characteristic features warranted the diagnosis of a neuroblastoma of the cerebellum. The nature of this rare intraparenchymal tumour in infants is also briefly discussed.