Oral administration of cilnidipine to patients with hypertensive intracerebral hemorrhage in the acute stage: significance and role of an N-type calcium channel blocker.

BACKGROUND: Elevated blood pressure (BP) causes rebleeding or enlargement of intracerebral hematomas. AIMS: How a long-acting oral calcium channel blocker, cilnidipine, could control BP in the acute stage of cerebral hemorrhage was evaluated. METHODS AND RESULTS: Cilnidipine given within 3 days of hospitalization has more benefit than cilnidipine given after 4 days of hospitalization; it can reduce the amount of intravenous nicardipine, and it can help to maintain the BP below 80% of the initial BP. Surgical removal of the hematoma has no benefit in reducing the amount of intravenous nicardipine and maintaining the BP below 80% of the initial BP. CONCLUSION: In order to reduce the total amount of intravenous nicardipine and to maintain the BP below 80% of the initial BP, oral administration of a long-acting N-type calcium channel blocker, cilnidipine, is useful and important, independent of whether the hematomas are surgically removed.

Analyses of the factors influencing bone graft infection after delayed cranioplasty.

BACKGROUND: Several factors influencing bone graft infection after delayed cranioplasty are analyzed in order to reduce the occurrence of infection. METHODS: For about 10 years, from March 1995 to February 2005, delayed cranioplasty was performed for 206 cases. The cases comprised 124 males and 82 females. Age distribution of the patients ranged from 6 months to 79 years old. The mean postoperative follow-up period was 1834 days. Autogenous bone, which was preserved in 100% ethanol at -20 degrees C and autoclaved before operation, was used in 54 patients. Polymethylmethacrylate (PMMA) was used in 55 patients. Custom-made PMMA was used in 3 patients. Custom-made titanium mesh was used in 77 patients. Custom-made ceramics (Alumina-ceramics 10 cases and hydroxyapatite 7 cases) was used in 17 patients. FINDINGS: Autoclaved and autogenous bone graft and PMMA have a significantly high rate of graft infection. Titanium mesh has the significantly lowest rate of graft infection. Alumina-ceramic has a merit that it has sufficient strength, however the number of cases using custom-made ceramics including alumina-ceramic was relatively small, and thus we cannot find significant differences in infection rate compared with that of other materials. There was no statistically significant difference in the bone graft infection rate among four categories of preceding diseases; cerebrovascular diseases, head trauma, infectious diseases, and brain tumour. CONCLUSION: Autoclaved and autogenous bone grafts and PMMA have a significantly higher rate of graft infection. Titanium mesh has the significantly lowest rate of graft infection.

Obstructive hydrocephalus caused by intraventricular collapse of malacotic brain. Case report.

The authors present the case of a 68-year-old man who experienced acute obstructive hydrocephalus after having suffered an infarction in the occipital lobe. Histopathological and serial neuroimaging examinations revealed that portions of a large disintegrating occipital infarct had entered the lateral ventricle and obstructed the passage of cerebrospinal fluid (CSF). Ventricular drainage was performed for 2 weeks until the patient's hydrocephalus resolved. The CSF initially contained a high concentration of protein (1070 mg/dl), a high leukocyte count of 115 cells/mm3, and a rich fibrinous exudate. Findings in the present case indicate that collapse of a periventricular ischemic lesion into the ventricles may sometimes occur not only after cerebral hemorrhage but also after cerebral infarction.

Factors in the natural history of chronic subdural hematomas that influence their postoperative recurrence.

OBJECT: Factors affecting the postoperative recurrence of chronic subdural hematomas (CSDHs) have not been sufficiently investigated. The authors have attempted to determine features of CSDHs that are associated with a high or low recurrence rate on the basis of the natural history of these lesions and their intracranial extension. METHODS: One hundred six patients (82 men and 24 women) harboring 126 CSDHs who were treated at Tokyo Kosei Nenkin Hospital between January 1989 and April 1998 were studied. Types of CSDHs were classified according to hematoma density and internal architecture, and the intracranial extension of the hematomas were investigated. The postoperative recurrence rate was calculated for each factor. Based on the internal architecture and density of each hematoma, the CSDHs were classified into four types, including homogeneous, laminar, separated, and trabecular types. The recurrence rate associated with the separated type was high, whereas that associated with the trabecular type was low. Chronic subdural hematomas are believed to develop initially as the homogeneous type, after which they sometimes progress to the laminar type. A mature CSDH is represented by the separated stage and the hematoma eventually passes through the trabecular stage during absorption. Based on the intracranial extension of each hematoma, CSDHs were classified into three types, including convexity, cranial base, and interhemispheric types. The recurrence rate of cranial base CSDHs was high and that of convexity CSDHs was low. CONCLUSIONS: Classification of CSDHs according to the internal architecture and intracranial extension may be useful for predicting the risk of postoperative recurrence.

Relationship between drainage catheter location and postoperative recurrence of chronic subdural hematoma after burr-hole irrigation and closed-system drainage.

OBJECT: This study was conducted to determine the best position for the subdural drainage catheter to achieve a low recurrence rate after burr-hole irrigation and closed-system drainage of chronic subdural hematoma (CSDH). METHODS: The authors studied 63 patients with CSDH in whom the drainage catheter tip was randomly placed and precisely determined on postoperative computerized tomography (CT) scans and 104 patients with CSDH in whom CT scans were obtained 7 days postsurgery. The location of the subdural drainage catheter, the maximum postoperative width of the subdural space, and the percentage of the ipsilateral subdural space occupied by air postoperatively were determined and compared with the postoperative recurrence and reoperation rates. Patients with parietal or occipital drainage had a higher rate of CSDH recurrence and much more subdural air than those with frontal drainage. In addition, patients with residual subdural air demonstrated on CT scans obtained 7 days postsurgery also had a higher recurrence rate than those without subdural air collections. Furthermore, patients with a subdural space wider than 10 mm on CT scans obtained 7 days postsurgery had a higher recurrence rate than those with a space measuring 10 mm or less. CONCLUSIONS: The incidence of postoperative fluid reaccumulation seems to be reduced by placing the tip of the drainage catheter in the frontal convexity and by removing subdural air during or after surgery.

Increased sarcolemmal permeability in the cerebral artery during chronic spasm: an assessment using DNA-binding dyes and detection of apoptosis.

Alteration of sarcolemmal permeability was evaluated in the cerebral artery after subarachnoid hemorrhage. Significance of membrane dysfunction in the pathogenesis of chronic spasm and contribution of apoptosis were investigated in a canine model. Permeability of the smooth muscle cell (SMC) membrane was assessed by double staining with a hydrophilic (ethidium bromide [EB]) and a lipophilic (Hoechst 33342) DNA-binding dye. Quantitative observations were made with a ultraviolet-fluorescence microscope and a ultraviolet-laser confocal microscope. Occurrence of apoptosis was studied using electrophoresis and TUNEL method. In the normal arteries, nuclei of SMC were stained with Hoechst 33342 but not with EB. In the spastic arteries, SMC in the inner layer of the tunica media were stained with EB. The incidence of EB-positive cells reached maximum on day 7 (45 +/- 19%) and decreased in 2 to 4 weeks (13 +/- 5.2% and 5.0 +/- 2.1%, respectively), in parallel with amelioration of spasm. Electron and light microscopic observations revealed increased density of SMC cytoplasm with widening of the extracellular space. Necrosis was not evident. Apoptosis was not detected by the two methods. These results demonstrate that an augmentation in sarcolemmal permeability takes place during the course of chronic vasospasm and suggest its close correlation to pathogenesis.

Snowboard head injury: prospective study in Chino, Nagano, for two seasons from 1995 to 1997.

BACKGROUND: The popularity of snowboarding has been growing rapidly throughout the world. To date, however, the risk of head injury associated with this relatively new winter sport, especially in comparison with alpine skiing, has not been well analyzed. This study was conducted to assess the risk of head injury in snowboarding and to elucidate its features in comparison with skiing head injury. METHODS: We prospectively analyzed 301 cases of head injuries related to snowboarding or skiing experienced from December of 1995 to May of 1997 at our institution, which is located close to the most popular skiing areas in Japan. Of those injuries, 143 cases were snowboard related and 158 cases were ski related. In addition to appropriate medical evaluation and medical care, detailed examination was performed on every patient to determine various factors, including sex, age, skill level, cause and mechanism of the accident, and the side of impact to the head. The data are statistically analyzed to elucidate unique features of snowboard head injury. RESULTS: During the study period, 2.2 million snowboarders and 4.2 million skiers visited the five skiing facilities that are covered by our hospital. Thus, the incidence of head injury was 6.5 per 100,000 visits for snowboarders and 3.8 per 100,000 visits for skiers. Beginning snowboarders more frequently sustained head injuries compared with beginning skiers (60 of 142 vs. 48 of 154, p = 0.022). Likewise, frequent causes of snowboarding head injuries were fall during jumping (43 of 139 vs. 2 of 147, p<0.0001), falling backward (67 of 127 vs. 49 of 144, p = 0.001), and occipital impact (67 of 126 vs. 49 of 147). More importantly, there were nine major head injury cases (6.3%) in snowboard head injuries in contrast to only two such cases found in skiing head injuries (1.3%). Of 11 major head injury cases, 10 were caused by occipital impact. CONCLUSION: These results indicate that snowboarders, particularly beginners, are at higher risk for head injury, frequently involving occipital impact, and could lead to more major head injuries. We propose that measures should be taken to protect the head, especially the occiput, in snowboarding.

Postoperative residual tumor growth of meningioma can be predicted by MIB-1 immunohistochemistry.

BACKGROUND: Meningiomas are benign tumors that can be cured by surgical removal. However, tumors located deeply within or close to vital structures cannot be removed completely and require repeated surgery. This study was designed to clarify whether immunohistochemical study using MIB-1 monoclonal antibody is useful for determining the rate of regrowth for this tumor. METHODS: Tumor volume doubling time (Td) was measured by using computed tomography or magnetic resonance imaging neuroimages during 29 different follow-up periods after surgery. MIB-1 monoclonal antibody was used to stain Ki-67 proliferating cell antigen in surgical specimens, and the MIB-1 staining index (SI) was determined independently of neuroimaging analysis. These two values and other clinical parameters were analyzed statistically. RESULTS: The Td values varied from 19-6830 days (median, 350 days); the Td values were <365 days in 15 cases, 365-730 days in 8 cases, and >730 days in 6 cases. There was no significant correlation between age and Td value, but all 6 patients whose Td values were >2 years were age >50. There was a strong inverse correlation between log(Td) and MIB-1 SI (P < 0.001). In three cases, more than three surgical procedures were performed for tumor recurrence. The MIB-1 values did not increase at the time of the first recurrence but increased at later recurrences. The calculated Td values also were not shortened until the second recurrence. CONCLUSIONS: Using the MIB-1 SI makes it possible to predict the regrowth potential of a tumor after initial surgery.

[Efficacy of the TURBO-fluid attenuated inversion recovery spin echo sequence of MRI as a preoperative neuroradiological examination].

Whenever the extirpation of intracranial tumors is planned, neurosurgeons always keep their eyes on the cerebrospinal fluid (CSF) space around intracranial tumors. If enough space exists in the neighborhood of the tumors, the damage to adjacent parenchyma may be reduced by the procedure through the CSF space. A newly advanced MRI pulse sequence: the FLAIR (fluid attenuated inversion recovery) imaging, in which a long TE spin echo sequence is used with suppression of the CSF with an inversion pulse, displays the CSF space as a no-signal intensity area. There have been only a few reports, however, on the FLAIR pulse sequence of brain tumors as yet. We examined 34 cases of intracranial tumors by FLAIR images and analyzed the advantages and disadvantages of the FLAIR pulse sequence for decision making on tumor removal. Making use of the FLAIR pulse sequence, the CSF space is depicted as a no-signal intensity area and much more information about perifocal edema and the invasion area around the tumors can be provided than that provided by the other ordinary pulse sequences (T1 weighted images, T2 weighted images and Proton weighted images). Therefore, operative strategies can be more easily worked out on the FLAIR images. Furthermore, the difference between arachnoid and epidermoid is able to be detected on the FLAIR images. Nevertheless, on FLAIR images, the tumors without perifocal edema or invasion to adjacent parenchyma were not apparent and the difference between tumoral dissemination into multi-ventricular space and the periventricular artifact of FLAIR images could not be distinguished. The FLAIR pulse sequence has other artifacts like intraventricular flow related enhancement and so on. If the images are carefully checked up on the above-mentioned points, the FLAIR pulse sequence of MRI can not fail to be useful in making plans for operations on intracranial neoplasms.

[A case of middle cranial fossa meningioma extending into the infratemporal fossa: an approach to the pterygoid extension of the sphenoid sinus via the infratemporal fossa].

A case of middle cranial fossa meningioma extending into infratemporal fossa and the pterygoid process is presented. The patient had a sphenoid sinus extending inferolaterally into the pterygoid process, which is known as pterygoid extension of the sphenoid sinus. This type of variation of the sphenoid sinus allowed a safe and well-oriented approach to the pterygoid process via the infratemporal fossa. The tumor extending into the pterygoid process was removed successfully without damaging any surrounding structures, e.g. maxillary nerve or Vidian nerve. However, pterygoid extension of the sinus is seen in only 40% of cases. Therefore, close preoperative examination with bone window CT scan is mandatory before employing this approach.

Chronic encapsulated expanding hematoma in association with gamma knife stereotactic radiosurgery for a cerebral arteriovenous malformation. Case report.

The authors report a rare case of a patient with a chronic encapsulated expanding hematoma and progressive neurological deterioration who presented 2 years after gamma knife radiosurgery for a cerebral arteriovenous malformation (AVM). A tough capsule containing multiple layers of organized hematoma resulting from previous bleeding was confirmed surgically. Histological examination revealed that the capsule consisted of a dense collagenous outer layer and a granulomatous newly vascularized inner layer with marked fibrosis. Hemosiderin deposits were frequently observed in the inner layer, which suggested recurrent minor bleeding from fragile vessels in this layer. An AVM was found in the hematoma, which had degenerated as the result of radiosurgery. A cross-section of the abnormal vessels showed various stages of obliteration due to intimal hypertrophy. The clinical course, radiological features, and histological findings in this case were compatible with those of previously reported chronic encapsulated hematomas. A possible mechanism of hematoma formation and its expansion are discussed.