Spontaneous intracranial hemorrhage caused by brain tumor: its incidence and clinical significance.

Hemorrhage from brain tumor was confirmed clinically, surgically, or on autopsy in 94 of 1861 cases (5.1%) treated during the past 18 years: 49 of 311 pituitary adenomas (15.8%) and 45 of 1550 other brain tumors (2.9%). The higher incidence of hemorrhage from pituitary adenoma was statistically significant (p less than 0.001). In brain tumors other than pituitary adenoma, the incidence of hemorrhage was significantly higher in the patients under 14 years old (17 of the 322 cases, 5.3%) than in the patients over 15 years old (28 of the 1228 cases; 2.3%) (p less than 0.001). Nineteen patients showed no evidence of clinical symptoms related to bleeding. Twenty-six patients had a definite history of an acute episode that suggested sudden bleeding. In 11 of these, the apoplectic syndrome was the initial presenting symptoms. The incidence of hemorrhage was not statistically correlated with sex. The hemorrhage was intratumoral in 30 cases, intracerebral in 7, subarachnoid in 7, and subdural in 1. The tumors were supratentorial in 36 cases, pineal in 1, and infratentorial in 8. Primary and metastatic choriocarcinoma and primary embryonal carcinoma seemed to cause hemorrhage most frequently. The following precipitating factors were found in 7 of the 17 patients aged under 14: ventricular drainage in 2, ventriculoperitoneal shunt in 2, carotid angiography in 1, head injury in 1, and leukemia in 1. Seven of the 17 patients under 14 years old died of massive bleeding from the tumor. Unless there is evidence of vascular disease such as cerebral aneurysm, vascular malformation, or hypertensive cerebrovascular disease, intracranial hemorrhage should be suspected of being due to a brain tumor.

Open surgery assisted by the neuronavigator, a stereotactic, articulated, sensitive arm.

A new computed tomographic-stereotactic device that translates the operating point onto preoperative computed tomographic (CT) images, the Neuronavigator, has been developed. We have applied this system to various neurosurgical procedures to examine its usefulness. The system consists of a 6-joint sensing arm and a 16-bit personal computer. It projects the location of the arm tip onto a corresponding CT slice with a cursor that guides the surgeon toward the intracranial target during open surgery. The system also projects the location of the tip onto angiograms, and when used in conjunction with echography or a transcranial Doppler (TCD) flow meter, the surgeon's ability to navigate is enhanced. Sixty-eight patients underwent operation with the Neuronavigator. The navigation system worked as the core of a multimodal three-dimensional data base that proved to be useful during surgery. The maximum detection error was 2.5 mm, which was considered sufficient for open microsurgery. It also proved useful in designing the position of a craniotomy, in targeting deep-seated mass lesions, and in tracing the tumor edge, which had been identified on a CT scan. When the angiogram was combined with the navigator, it became easy to identify key vessels within a small operating field. The system was also combined with a TCD flow meter. This combination makes it possible to translate the measuring point of the TCD directly into CT coordinates, improving the precision of location of the TCD probe. The Neuronavigator combines various diagnostic images into one database and effectively guides the surgeon during surgery.

Clinical course and surgical prognosis of 33 cases of intracranial epidermoid tumors.

Thirty-three cases of intracranial epidermoid tumors treated during the past 25 years were analyzed with regard to clinical manifestations, recurrence rates related to the extent of surgery, and long-term survival rates. Epidermoid tumors caused various symptoms, especially in the cerebellopontine angle (15 cases), of which a transient remission of symptoms was observed in 4 cases (23.5%). The average time from initial symptoms to surgery was much shorter in suprasellar region and third ventricular locations (average of 11 months) than in other locations (average of 7 years). In 28 patients (84.9%), the tumor was removed totally or subtotally. Most of the patients could lead an independent and useful life after operation (93.1%). Among the 29 patients in a long-term follow-up survey, seven tumors recurred after an average interval of 8 years and 10 months (from the first to second operation) and 12 years and 6 months (from the second to third operation). Patients with recurrent tumors were successfully treated, and excellent functional prognosis was observed even after the second or third operation. The 20-year survival rate was 92.8% (Kaplan-Meier method).

Changes in extracellular potassium concentration in cortex and brain stem during the acute phase of experimental closed head injury.

A high potassium concentration ([K+]o) in brain tissue impedes neuronal activity, as observed in spreading cortical depression. Experimental studies were performed on mice and rats to determine the role of changes of [K+]o in cerebral concussion. In the first experiment, a 600 gm-cm impact was delivered to the vertex of the mouse skull. This impact induced arrest of spontaneous movement for 465 +/- 55.9 seconds (mean +/- SD), accompanied by apnea, bradycardia, and low-voltage electroencephalographic recordings (EEG). The injury was also frequently followed immediately by epilepsy. This impact induced an increase of cortical [K+]o from the control level of 4.1 +/- 1.8 mM to 20-30 mM, with gradual recovery within 30 minutes to the control level. In the second experiment, an impact of 9000 gm-cm was delivered to the midline parieto-occipital area of the rat and produced concussion-like phenomena similar to those elicited in mice. This level of trauma induced a significant increase of cortical [K+]o from the control level of 4.2 +/- 0.8 mM to 20-50 mM in all of the rats, and also a significant increase of brain-stem [K+]o from 3.9 +/- 0.6 to 20-30 mM in 73% of the rats. In these latter rats, the impact also induced apnea and a transient elevation of blood pressure, and resulted in low-voltage EEG recordings. In 23% of the rats in which [K+]o changes in the brain stem were not significant, the impact caused a transient reduction of blood pressure. The present study disclosed that an increase of [K+]o in the cerebral cortex and also in the brain stem is an important element in the phenomenon of concussion.

The efficacy of radiotherapy for craniopharyngioma.

A series of 125 patients who underwent surgery for craniopharyngiomas was evaluated to assess the efficacy of radiation therapy: 45 patients had received radiotherapy and 80 had not. These patients included all operative survivors (excluding cases with total tumor removal) treated during the 30 years from 1950 to 1979. Median survival time of the irradiated group was greater than 10 years, whereas it was 3.12 years for the nonirradiated (or control) group. The 5- and 10-year survival rates were 88.9% and 76.0% for the irradiated group, and 34.9% and 27.1% for the control group, respectively. Overall comparison, using the Lee-Desu statistical method, revealed that there was a very high statistical significance (at the level of p less than 0.0001) in the difference between the survival times of the irradiated and control groups. The influence of the following factors on the effectiveness of radiotherapy was analyzed: age of the patient at the first operation, sex, date of surgery, the extent of tumor removal, the size of the tumor, the composition of the tumor (cystic or solid), whether the tumor was calcified or not, the histological subtype of the tumor, the presence of intracranial hypertension, the grade of visual failure, and the presence or absence of diabetes insipidus, altered mentation, and adiposogenital syndrome. The results indicated that, when total removal of the tumor is impossible, radiotherapy should be administered.

Skull tumor simulating sinus pericranii. Case report.

A case of skull tumor simulating sinus pericranii is presented. The tumor was situated in the occiput near the midline and it was thought to satisfy the diagnostic criteria of sinus pericranii. At operation the tumor proved to be eosinophilic granuloma with intratumorous hemorrhage associated with epidural hematoma.

Growth suppression and astrocytic differentiation of glioma cells by interleukin-1.

The effect of recombinant human interleukin-1 (rHuIL-1) derivatives on human glioma cell lines was examined in vitro. Five glioma cell lines, U-251 MG, U-373 MG, U-87 MG, A-172, and T98G, were incubated in medium containing 1% fetal calf serum and various concentrations of different type of rHuIL-1: OCT-43 (rHuIL-1 beta), OCT-7000 (rHuIL-1 alpha), and OCT-8000 (rHuIL-1 alpha). The high-affinity IL-1 receptors were expressed in the U-251 MG and U-373 MG cell lines, and rHuIL-1 was found to suppress cell growth and to induce morphological differentiation of these cell lines. Growth inhibition occurred in a dose-dependent manner in concentrations or rHuIL-1 ranging between 1 and 100 ng/ml. Interestingly, rHuIL-1 induced a transient growth of glioma cells shortly after administration, then suppressed cell growth with accompanying elongation of cytoplasmic processes. This unique process of transient growth stimulation followed by growth suppression was parallel to the efficacy of bromodeoxyuridine uptake in the rHuIL-1-treated cells. Concomitantly, accumulation of glial fibrillary acidic protein and cyclic adenosine monophosphate contents was observed in four glioma cell lines. Continuous rHuIL-1 treatment for longer than 30 days elicited irreversible astrocytic terminal differentiation. These results indicate that IL-1 is an effector on the growth regulation of glioma cells, resulting in astrocytic differentiation in vitro.

Statistical studies on evaluation of mild disturbance of consciousness. Study of a simpler scale for clinical use.

In an effort to express the grades of mild disturbance of consciousness (MDOC), or clouding of consciousness, 25 items were selected for application in clinical examination. Factor analysis of the 25 items revealed that MDOC has a two-factor structure; namely, the performance factor (F1) and the verbal factor (F2). This structure was maintained in the sequential examinations. Guttman's scale analysis showed that the scale using the 25 items may be considered to approximate a unidimensional scale. By item selection according to communality, the 25 items could be reduced to 12 items without losing the two-factor structure or the usefulness and reliability of the examination. The principal component analysis (PCA) score, the F1 score, and the F2 score, calculated from the 12 items, were found to be good scales to describe an overall picture and characteristics of the F1 and the F2 of MDOC, respectively. Furthermore, by means of the characteristic curve (ogive) method, it was revealed that MDOC consisted of four clusters of items, the F2 factor (mild), F1 factor (mild), F2 factor (moderate), and F1 factor (moderate), according to the MDOC severity, so that a simpler scale composed of a representative item from each cluster could be constructed which exhibited a high correlation coefficient with the original PCA score.

The role of extracellular potassium in early epilepsy.

Clinical studies indicate that early epilepsy after injury may be associated with some transient and reversible pathophysical processes of the brain. It has been proposed that epileptogenesis in the neocortex and hippocampus may be related to potassium ion accumulation in extracellular spaces. To investigate this hypothesis, we measured [K+]0 using potassium-sensitive microelectrodes in the sensorimotor cortex of cats during early seizures induced by trauma. The [K+]0 increases associated with seizure activity ranged from 14.6 to 25.1 mM, and these were significantly higher than those unassociated with spikes or seizure discharges. Moreover, high K+ solutions (15 mM or more) directly applied to the cortex produced spiking and seizures. These results seem to support the hypothesis that accumulation of [K+]0 is related to development of early epilepsy.

Dural arteriovenous malformation treated by artificial embolization with liquid silicone.

The successful treatment of a dural arteriovenous malformation in the region of the transverse-sigmoid sinus by artificial embolization with liquid silicone is reported. The clinical and radioanatomical characteristics of the lesion are described. The technical feasibility of embolization is discussed and compared with other surgical treatments.

Spontaneous cerebrospinal fluid otorrhea.

A case of spontaneous cerebrospinal fluid otorrhea with recurrent meningitis is reported. The route of cerebrospinal fluid leak was through the internal auditory meatus. The cerebrospinal fluid otorrhea was stopped by packing the meatus with muscle and Gelfoam.

Estimation of intracranial pressure using computed tomography scan findings in patients with severe head injury.

The relationship between initial intracranial pressure and the findings of the first computed tomography scan on admission was assessed in 100 consecutive moderate-to-severe head injury patients using a method of multiple regression analysis. Intracranial pressure was measured through a slender subarachnoid catheter with a transducer. Thirty-nine checkpoints of computed tomography findings, including a shift of midline structure, the status of ventricles or cisterns, and the amount of subarachnoid hemorrhage, were investigated. The results were as follows: (1) The computed tomography findings that contributed to estimating intracranial pressure were the appearance of cisterns, the size of a subdural hematoma (number of slices), ventricular size, status of subarachnoid hemorrhage, status of cerebral contusion, magnitude of midline shift, and ventricular index, in that order. (2) Approximately 80% of predicted cases of intracranial pressure were included within the range of measured intracranial pressure +/- 10 mmHg. When the predicted intracranial pressure was less than 30 mmHg, the discrepancy between both intracranial pressures was small. It is concluded that an equation using several computed tomography findings gives a reasonably accurate intracranial pressure for the initial stage of severe head injury.

Three-dimensional digitizer (neuronavigator): new equipment for computed tomography-guided stereotaxic surgery.

A new device was invented as an adjunct for computed tomography (CT)-guided stereotaxic or open neurosurgery. It is composed of a multijoint three-dimensional digitizer (sensor arm) and a microcomputer, which indicates the place of the sensor arm tip on preoperative CT images. Computed tomography scan is performed preoperatively with three markers placed on the nasion and ears. At surgery, after fixing the patient's head and the sensor arm, sampling of the standard points was done to translate the position of the tip of the sensor arm onto the CT images displayed on a computer screen. In this way positional data from conventional preoperative CT scan can be directly transferred into the surgical field. This system has the unique feature of introducing CT-guided stereotaxis into conventional open neurosurgery.

Human interferon-beta therapy for cerebral primitive neuroectodermal tumors--two case reports.

A 5-year-old girl and a 2-year-old boy presented with recurrent cerebral primitive neuroectodermal tumor (PNET) and were treated with intravenous administration of human fibroblast interferon (HuIFN-beta) which was continued as outpatient maintenance therapy. Both patients showed a partial response and were still alive 14 months and 2 years after diagnosis. Our results suggest that HuIFN-beta is an effective therapy for PNET, and can be used as long-term maintenance therapy without serious side effects.

[Protective effect on the brain of ion-blockers in experimental head injury].

It has been known that various derangements in ionic homeostasis develop following neural trauma. In particular, potassium efflux out of and calcium influx into the cells are thought to play important roles in causing cell damage. Concomitantly we have previously reported that increased extracellular potassium per se provoked by head injury induces convulsive seizure such that the sustained high extracellular potassium leads to animal death. The purpose of the present study was further to examine the beneficial effect of drugs which could inhibit such detrimental ion movements in experimental head injury. Awake male mice of dd-strain were restrained and subjected to head injury using a bakelite weight of 30 gm dropped from a height of 17.6 cm above the skull. This injury resulted in immediate loss of consciousness in 100%, convulsive seizure in about 70% and death in about 30% of animals. The severity of consciousness disturbance was evaluated by a pair of indices in time interval; time required for the recovery of righting reflex (RR) and for the recovery of spontaneous movement (SM). Ethacrynic acid, a loop diuretics, blocks carrier-mediated chloride transport into astroglia associated with sodium and water in the presence of high extracellular potassium. Animals were treated with either 0.5-1.0 mg/kg or 2.0-4.0 mg/kg of ethacrynic acid administered via tail vein 10 min before injury. In the other group of animals, a calcium entry blocker, flunarizine was injected intraperitoneally in doses 5, 10 and 20 mg/kg one hour pre-insult.(ABSTRACT TRUNCATED AT 250 WORDS)

[Dural arteriovenous malformation in posterior fossa treated with artificial embolization using a liquid silicon rubber, phycon (author's transl)].

Many cases of dural arteriovenous malformation have been reported recently. However, the surgical treatment for these diseases has not been established yet. We propose a new method of treatment on this peculiar vascular diseases, that is one of the artificial embolizations; A catheter is inserted into feeding artery, from which liquid silicon rubber, Phycon, is injected. The rubber is hardened in the vascular net-work. It can not pass into drainer because of its viscosity. Therefore the malformation never develope again. We tried this new method on 46-year-old woman, who suffered from subarachnoidal bleeding, tinnitus and headache. The left common carotid and vertebral angiography revealed dural arteriovenous malformation in posterior fossa (Fig. 1); the feeding arteries of which were middle meningeal arteries, occipital artery, and tentorial artery, etc; the drainers were transverse and sigmoid sinuses. We treated for this case with above-mentioned method; The liquid plastic of 1 - 2 ml injected into each of the main feeding arteries, namely two middle meningeal arteries and occipital artery. Postoperative angiograms revealed this technic was convenient and sufficient for the treatment of dural arteriovenous malformations (Fig. 7).

[Occipital tumor simulating pericranial sinus (author's transl)].

A case of occipital tumor simulating sinus pericranii was reported. The patient was a 4-year-old girl who suffered from headache and nausea following head injury on midoccipital tumor, but had no remarkable neurological deficit. Her occipital tumor was soft, compressible redish and cyst-like without bruit. Conray cystography of this tumor showed superior sagittal sinus like shadow (Fig. 4). Total removal of the tumor associated with epidural hematoma was performed. Histologically this tumor was confirmed as eosinophilic granuloma. Pathogenesis of this case is following, since patient's tumor was blowed, intratumor-bleeding occurred cosequently and the bleeding flowed into epidural space. So the tumor simulated sinus pericranii (Fig. 5.).

[A case of spontaneous CSF otorrhea associated with recurrent meningitis (author's transl)].

A 5-year-old girl was admitted to our hopsital on June, 1972, because of meningitis and CSF otorrhea. She had not suffered from head trauma or otological infective disease. Right temporal craniotomy was carried out on October, 1972, but no pathological findings on the anterior surface of the petrous bone was detected, so, the right middle ear bottom was packed with fascia graft by otologist, which stopped the CSF otorrhea for seven months. But the otorrhea recurred on June, 1973, when she caught cold. She was readmitted to our hospital because of recurrent meningitis. On November 7, 1973, when the meningitis abated, posterior fossa exploration was performed microsurgically. Strong arachnoid adhesion due to recurrent meningitis and enlargement of the right internal auditory meatus was observed. Probe could be inserted into the internal auditory meatus easily at a depth of 1.5 cm. Saline which was injected into the meatus from the probe flowed into the right middle ear. So the internal auditory meatus was packed with Gelfoam and muscle piece. By means of this procedure, CSF otorrhea was healed completely. Spontaneous CSF otorrhea, which was initially reported in 1897 by Escat, is a very rare disease. Only 15 cases have been reported in the literature. Two main possible routes of CSF leakage were reported, the one is via the internal auditory meatus, the other is via the cochlear aqueduct (Fig. 3). The former cases were more frequent than the latter. Our case belongs to the former type. (Fig. 4)

[A case of malignant lymphoma in the skull base].

A case of malignant lymphoma located in the clivus, sella and cavernous sinus is reported. A 46-year-old female was hospitalized with a 3-week history of diplopia. Neurological examination showed left oculomotor, trochlear, abducens and hypoglossal nerve palsy. Improvement of cranial nerve palsy was achieved with the administration of prednisolone but it was only transient. Laboratory studies and endocrinological examination showed almost no abnormal findings. Skull x-ray film revealed a widely damaged base. MR studies showed a homogeneously enhanced mass lesion in the clivus, sella and bilateral cavernous sinus. Partial removal of the lesion was performed via the transsphenoidal route. The histopathological diagnosis of the mass was consistent with diffuse, medium sized cell, B-cell type malignant lymphoma. A postoperative systemic evaluation by tumor scan with 67Ga disclosed no abnormal uptake except in the skull base. Postoperatively, the patient was treated with radiation, a total of 50 Gy, followed by chemotherapy every 3 week consistent of cyclophosphamide, vincristine, pirarubicin, bleomycin, procarbazine and prednisolone. The cranial nerve symptoms disappeared during radiation therapy. The MR studies after three courses of chemotherapy revealed almost complete remission. The patient died of acute progression of pneumonia without any evidence of the recurrence of malignant lymphoma 10 months after the operation. Skull base involvement of malignant lymphoma is unusual. Five cases of malignant lymphoma invading the skull base have been reported since 1987. In most cases, the lesion originated from paranasal sinuses and was usually accompanied with intradural extensions. In the case we have reported there was no intradural invasion of the tumor.(ABSTRACT TRUNCATED AT 250 WORDS)

[Treatment of recurrent craniopharyngioma].

Treatment results on 48 patients with "recurrent" craniopharyngioma treated by surgery or/and radiation are analyzed. Median relapse-free survival time was 43.6 months in patients treated initially with radiation and 22.2 months without. Operative death occurred in 17% of all patients and in 3 out of six patients after total removal. The five- and ten-year survival rates were 91.7% and 66.8%, respectively, for 14 patients treated with combined surgery and radiation therapy. For 26 patients treated with surgery, the survival rates were 20.3% and 10.1%. All of 6 patients, who had received both initial and later radiotherapy, were well 1/2 to 18 years later without clinical evidence of radiation injury. These results lead us to the following conclusions: 1) A radical surgery in recurrent cases has the higher risks of mortality and morbidity than that of the first radical surgery. 2) Radiation therapy improved the survival rate of patients with "recurrent" craniopharyngioma. 3) After initial radiation therapy, additional irradiation was allowed based on the scale of nominal standard dosage and the estimation of "decay factor".