Neurological grades of patients with poor-grade subarachnoid hemorrhage improve after short-term pretreatment.

OBJECTIVE: Short-term pretreatment of patients with subarachnoid hemorrhage, but without hematomas causing mass effect, who presented in poor neurological condition at admission was evaluated as a protocol for the selection of candidates for radical surgery. METHODS: One hundred-three patients were pretreated for 12 hours with control of blood pressure and intracranial pressure, using diuretic agents and/or ventricular drainage. RESULTS: Neurological improvement was observed for 32 of 47 patients in Grade IV at admission and 23 of 56 patients in Grade V (P < 0.01). Hydrocephalus requiring drainage was more common (P < 0.05) and the interval between onset and admission was shorter (P < 0.01) for the improved group. Clipping surgery was performed for all patients in Grade III or better and for patients in Grade IV who were less than 75 years of age and without systemic complications, i.e., 38 of 47 patients in Grade IV and 16 of 56 patients in Grade V at admission. Good outcomes (defined as moderately disabled or better on the Glasgow Outcome Scale) were achieved by 34 of 38 patients in Grade IV and 10 of 16 patients in Grade V (P < 0.01). The proportion of patients in Grade IV after pretreatment was lower for Grade IV (2 of 38 patients) than for Grade V (9 of 16 patients) (P < 0.00001). However, none of the 49 patients who underwent nonsurgical treatment achieved good outcomes. CONCLUSION: Our protocol may be beneficial for the selection of candidates for radical surgery among patients with subarachnoid hemorrhage but without hematomas who are in poor neurological condition at admission and for the improvement of postoperative outcomes.

Extrinsic pathway of blood coagulation and thrombin in the cerebrospinal fluid after subarachnoid hemorrhage.

OBJECTIVE: The involvement of thrombin in the pathophysiology of subarachnoid hemorrhage (SAH) was investigated by comparing thrombin expression and extrinsic pathway activation in the cerebrospinal fluid (CSF) and blood of patients with SAH with the neurological grades, outcome, and presence of delayed cerebral vasospasm. METHODS: Blood and CSF samples were obtained from 38 patients with SAH on Days 3 through 5, 7 through 9, and 12 through 14 after the onset of SAH. CSF samples were also obtained from control patients. Thrombin-antithrombin III complex, prothrombin fragment F1 +2, tissue factor, and tissue factor pathway inhibitor were analyzed using enzyme-linked immunosorbent assay. RESULTS: No markers in the blood or CSF were correlated with neurological grades and outcome. Thrombin-antithrombin III complex and prothrombin fragment F1 +2 levels were significantly higher in the CSF of patients with SAH than in the blood or the CSF of control patients and were significantly higher in patients with vasospasm than in patients without vasospasm on Days 7 through 9. Tissue factor levels were significantly higher in the CSF of patients with SAH than in the blood, but the levels were close to those in the CSF of control patients. Tissue factor pathway inhibitor levels in the CSF of patients with SAH and control patients were under the detection limit. CONCLUSION: Thrombin in the blood may not reflect the pathophysiology of SAH. Imbalance between tissue factor and tissue factor pathway inhibitor in the CSF may tend to thrombin generation under normal physiological conditions and also after SAH. Thrombin in the CSF may be involved in the pathophysiology of vasospasm.

Dissecting aneurysm of the anterior choroidal artery: angiographical and MR imaging findings.

BACKGROUND: Intracranial dissecting aneurysms are relatively rare. We present a rare case of a dissecting aneurysm originating from the anterior choroidal artery; this is the first reported case. CASE DESCRIPTION: A 42-year-old man suffered sudden onset of right hemiparesis and dysarthria. Computed tomography on admission revealed a small low density area in the posterior limb of the internal capsule. MR imaging revealed aneurysmal dilatation of the anterior choroidal artery, and angiography revealed aneurysmal dilatation and stasis of dye in the venous phase at the anterior choroidal artery, which resolved in the chronic stage. CONCLUSION: We describe a rare case of a dissecting aneurysm of the anterior choroidal artery. The radiological findings were characteristic of dissecting aneurysms in spite of the rare location.

Cerebral blood flow imaging in arteriovenous malformation complicated by normal perfusion pressure breakthrough.

BACKGROUND: A patient with normal perfusion pressure breakthrough (NPPB) after surgical removal of an arteriovenous malformation (AVM) was evaluated using single photon emission computed tomography cerebral blood flow (CBF) imaging. CASE DESCRIPTION: A 48-year-old man suffered consciousness disturbance because of an intraventricular hemorrhage and underwent ventricular drainage. Cerebral angiography showed a medium-sized AVM in the left parietal lobe. Three months after the ictus, a left parietal craniotomy was performed and total removal of the AVM was achieved. A brain region adjacent to the AVM with preoperative decreased vasoreactivity to acetazolamide showed marked hyperperfusion after AVM excision. Hemorrhage subsequently occurred in this area. CONCLUSION: CBF mapping seems to offer a noninvasive method for the preoperative identification of AVM patients at risk for NPPB, and to allow for early postoperative diagnosis of NPPB.

Effect of aging and castration on the changes in the levels of bone gamma-carboxyglutamic acid-containing protein in bone and serum of female rat.

Using female rats from 2 to 64 weeks old, the changes in bone gamma-carboxyglutamic acid-containing protein (BGP) levels in bone and serum were studied in relation to the changes in calcium metabolism during aging. Intestinal calcium transport, serum phosphorus level, bone origin serum alkaline phosphatase activity and serum BGP content were high in rapidly growing animals and then decreased with aging. Serum BGP content correlated well to bone origin serum alkaline phosphatase activity. Bone density, bone ash content and bone BGP content increased during aging. Bone BGP content was correlated to bone density which indicates the level of bone calcification. Moreover, the effect of castration on calcium metabolism and bone and serum BGP contents were observed in young (10 weeks old) and aged (40 weeks old) female rat at 12 and 24 weeks after operation. Intestinal calcium transport in ovariectomized rat was significantly lower than in sham operated rat. Serum phosphorus level and serum BGP content were increased in castrated female rat. However, serum calcium level and bone origin serum alkaline phosphatase activity did not show a significant change in castrated female rat. Bone density was significantly decreased in aged rat at 24 weeks after operation. During aging or castration, serum BGP content changed more than bone BGP content. The determination of change in serum BGP levels in various disorders of calcium metabolism would be very informative in future study.

Purification and characterization of calcium-binding protein containing gamma-carboxyglutamic acid from rat bone.

A gamma-carboxyglutamic acid (Gla)-containing protein was purified from rat femur cortical bone. The presence of 4 Gla residues in the rat protein was shown by amino acid analysis on alkaline and acid hydrolysates. The protein was extracted from rat cortical bone with 0.5 M EDTA (pH 7.6) and purified from the EDTA extracts by gel filtration on Sephadex G-100 and ion-exchange chromatography on DEAE-Sephadex A-25. The protein has a molecular weight of about 6,000 on the basis of amino acid composition. The protein had 56 amino acid residues containing significant amounts of Asp, Glu, and Gla (acidic amino acids). The protein showed calcium-binding activity with Kd = 0.2 mM and calcium-dependent electrophoretic mobility.

Inhibitory effect of cadmium on vitamin D-stimulated calcium transport in rat duodenum in vitro.

In vitro effect of cadmium on vitamin D-stimulated calcium transport in the rat was studied using the everted gut sac technique. Calcium transport was significantly inhibited by the addition of cadmium to the mucosal incubation medium. Furthermore, the kinetic analysis of inhibitory effect of cadmium on calcium transport revealed that the type of inhibition was competitive. The apparent "Km" and "Vmax" value for calcium was 1.0 mM, and 2.86 mumoles ml-1.hr-1, respectively. An apparent "Ki" for cadmium was 0.02 mM.

Sonic analysis for detection of cervical and intracranial vascular disease.

A sonic analysis system was developed for the detection of cervical and intracranial vascular disease. The system analyzes recorded sound signals converted to digital data, and plots the frequency, time interval after the QRS wave of the electrocardiogram, and amplitude on the graph using contour lines. Sonic analysis of 22 patients with and 23 patients without cerebrovascular disease identified a characteristic pattern of disease called the "circular pattern." Five of 10 patients with internal carotid artery stenosis, four of seven with cerebral aneurysms, three with cerebral arteriovenous malformation, and two of two with dural arteriovenous malformation showed the circular pattern. Only one of 23 control patients showed the circular pattern. This system is a promising method for cost-effective mass screening for the early detection of cerebrovascular disease.

Carcinomatous change in the cranial metastasis from a metastasizing mixed tumor of the salivary gland--case report.

A 57-year-old female who had had a mixed tumor of the submandibular gland for 30 years presented with a cranial metastasis in the ipsilateral occipital region. Detailed histological examinations of the primary tumor failed to detect any carcinomatous component. In contrast, the metastasis contained a carcinomatous component. This histological discrepancy was confirmed by assessment of the expression of Ki-67 antigen in these tumor specimens and comparison with five typical benign mixed tumors. Cranial metastasis of a histologically benign mixed tumor is extremely rare, and a carcinomatous change in the metastatic tumor is apparently unique.

[An autopsy case of a ruptured cerebral aneurysm treated with interlocking detachable coils].

We described an autopsy case of a ruptured aneurysmal subarachnoid hemorrhage treated with endovascular embolization by interlocking detachable coils. An 85-year-old male presented with sudden onset of severe subarachnoid hemorrhage. Cerebral angiogram revealed a right internal carotid-posterior communicating artery aneurysm. Post-operative angiogram revealed complete obliteration of the aneurysm, except for its orifice. Following the embolization of the aneurysm, tissue plasminogen activator was intrathecally perfused for anti-vasospasm treatment. Follow-up angiogram showed stable obliteration of the aneurysm, and no particular findings of cerebral vasospasm. The patient had been recovering without any neurological deficits, but died from pneumonia on the 25th day after the embolization. Autopsy findings revealed the disappearance of the subarachnoid hemorrhage, and no visible finding of cerebral infarction or edema. The inner lumen of the aneurysm was occupied by a mixture of the coils and the clots. The surface of the embolized coils was directly observed through the orifice of the aneurysm without any membranous substance from the inner lumen of the internal carotid artery. This pathological finding is different from the previously reported animal models in which the surface of the embolized coils was covered with endothelial membrane 2 weeks after embolization. Further examinations are required to clarify the pathogenesis of the endothelial regrowth.

[Fenestrated basilar artery aneurysm: case report].

The authors reported an operated case with an aneurysm arising from the proximal end of basilar artery fenestration, and discussed its etiology and surgical strategy. A 47-year-old woman presented with slight memory disturbance. Neuroradiologic examination revealed an aneurysm located on the proximal end of the basilar artery 12 x 9 mm in size at the level of the outer auditory meatus. The union of vertebral arteries had deviated toward the right side, and the aneurysmal dome had projected into the fenestration. Through the right far lateral approach, we applied two straight fenestrated clips X configuration to the aneurysm. Several authors have reported a variety of approaches for vertebrobasilar aneurysms along the midline with consideration of the height of the aneurysmal. However, another point of view is that attention should be paid to the direction of the clip blade and applied at the final clipping, because, for vertebrobasilar aneurysms adjacent to the midline, the surgical view and working space are extremely restricted.

[Giant thrombosed fusiform aneurysm at the branch of the middle cerebral artery presenting with intramural hemorrhage: a case report].

We report a rare case of a giant thrombosed fusiform aneurysm at the branch of left middle cerebral artery presenting with intramural hemorrhage of the aneurysm. A twenty-year-old man with familial and past history of migraine presented sudden temporalgia on August 13, 1995. Computed tomography (CT) scan on the day of the first attack revealed a well delineated high density area at the left Sylvian fissure, 2.5cm in diameter. Angiogram showed avascular area corresponding to the lesion, but no visualization of the aneurysm. On October 18, this patient presented sudden temporalgia again. CT scan on the day of the second attack indicated new intramural hemorrhage and surgery was performed on October 31. No evidence of subarachnoid hemorrhage was shown during the operation, and the lesion was proven to be a thrombosed fusiform aneurysm at the branch of the middle cerebral artery. The parent artery was clipped at both proximal and distal sides of the aneurysm, and the aneurysm was totally removed with success. Histological finding further supported the idea that the attacks mentioned were due to intramural hemorrhage of the thrombosed aneurysm. Postoperative course was uneventful and the patient was discharged without any neurological deficit. Intramural hemorrhage of a giant fusiform aneurysm is relatively rare, only reported in several autopsy cases. Furthermore, we failed to discover any comparable cases of giant fusiform aneurysm presenting symptoms directly caused by intramural hemorrhage of the aneurysm.

[A case of left occipital lobe hemorrhage in a patient with progressive systemic sclerosis: evaluation of cerebral angiography and histology].

Involvement of the central nervous system is uncommon in progressive systemic sclerosis, with only 2 reported cases associated with intracerebral hemorrhage detected by neuroimaging. A 55-year-old woman with a 10-year history of scleroderma presented with left occipital lobe hemorrhage manifesting as headache and vomiting. She had no signs of hypertension, diabetes mellitus and hyperlipidemia. CT and MRI, on admission, showed left occipital lobe hemorrhage with ventricular rupture and acute left subdural hematoma. Serial cerebral angiography was performed on day 0, day 7 and day 14, and found no evidence of aneurysm, arteriovenous multiformation or tumor stain in the left occipital lobe. However, the bilateral anterior cerebral arteries showed increasing segmental narrowing suggestive of vasculitis. Histological examination of a section from the brain cortex adjacent to the hemorrhage revealed no evidence of vasculitis, fibrinoid degeneration or amyloid deposition. Focal vasculitis may have occurred secondary to the homorrhagic lesion.

[Analysis of histological findings of testicular biopsies in male infertility].

Histological findings of testicular biopsy were studied following the Johnsen's score count method in 68 cases of idiopathic male infertility, and the relation between serum levels of luteinizing hormone (LH), follicle stimulating hormone (FSH), and testosterone (T) and histological findings were analyzed in the same cases. In oligozoospermia, there were no cases showing a Johnsen's score lower than 4. The score counts ranged widely from 1 to 9 in azoospermia. The cases with the Johnsen's score count lower than 4 revealed high values of serum LH and FSH and a low level of serum T. There was no relationship between Leydig cell accumulations or thickness of the seminiferous tubular walls and score values. Further examination using ABC (avidin biotin complex) method was carried out to find the localization of FSH and T in the testicular tissues. Immunohistochemical localization FSH was not noted in normal testicular tissues obtained the autopsy cases and testicular biopsy specimens of idiopathic male infertility. The localization of T was found in the Leydig cells and the Sertoli cells of normal and infertile testes. In the cases with the thickness of tubular walls, Sertoli cells were not stained. This fact might indicate that absence of T in Sertoli cells is related to spermatogenetic maturation only with the thickness of seminiferous tubular walls.

[Operative fiberoptic nephroureteroscope--removal of renal and upper ureteral stones].

Two types of operative fiberoptic nephroureteroscopes were developed with the cooperation of the Olympus Optical Company mainly to remove the upper urinary tract calculi. Removal of the renal and upper ureteral stones was attempted in nine cases. The ureter was dilated with olive tip, balloon and Teflon dilators alone or in combination. The combination of balloon and Teflon dilators seemed the most promising. As a result of ureteral dilation, operative fiberoptic nephroureteroscopes, 4.5 mm and 3.5 mm in diameter, could be passed into the ureter in all the cases and the stones could be visualized clearly. Four of the 7 upper ureteral stones and 1 of the 2 pelvic stones could be removed. The success ratio was 56%. The method of stone removal still requires improvement. At present, application of the operative fiberoptic nephroureteroscope is indicated for upper ureteral and renal stones less than 1.0 cm in diameter. With the improved techniques of stone removal using this fiberscope, the indications of extracorporeal shock-wave lithotripsy or percutaneous nephrolithotripsy will probably be greatly reduced in the near future.

[Effect of liarozole on the cell proliferation activity in the rat urinary bladder epithelium induced by N-butyl-N-(4-hydroxybutyl) nitrosamine].

INTRODUCTION AND OBJECTIVES: Recently, the chemopreventive effects of various drugs on N-Butyl-N-(4-hydroxybutyl) nitrosamine (BBN) induced rat urinary bladder carcinogenesis have been reported. The aim of this study was to evaluate the effect of liarozole, an antitumor agent that inhibits the metabolism of retinoids, on the initial stage of BBN induced rat urinary bladder carcinogenesis. MATERIALS AND METHODS: Seven-week-old, male Wistar rats were used. The rats were divided into four groups. All groups except control were allowed free access to the drinking water containing 0.05% BBN. Groups Lz40 (n = 5) and Lz80 (n = 5) were administered the liarozole solution, twice daily by gavage (40 mg/kg/day and 80 mg/kg/day, respectively). Group BBN (n = 5) was given no liarozole. The control group (n = 4) received no carcinogen. At 9 weeks after the start of the experiment, all rats were killed by ether anesthesia and their urinary bladders were taken for evaluation. The urinary bladders were fixed in 10% buffered formalin, embedded in paraffin, sectioned, and immunohistochemical staining using anti-proliferative cell nuclear antigen (PCNA) antibody was performed by the avidin-biotin-peroxidase complex (ABC) method. We calculated the PCNA positive rate and compared among the four groups. RESULTS: The PCNA positive rate of group BBN was 23.5 +/- 3.7%. Compared with group BBN, the PCNA positive rate of groups Lz40 and Lz80 were statistically less (16.4 +/- 4.3% and 9.8 +/- 2.6%, respectively). Furthermore, the PCNA positive rate of group Lz80 was statistically less than that of group Lz40. CONCLUSION: The results indicate that liarozole may inhibit the activity of cell proliferation in the initial stage of BBN-induced rat urinary bladder carcinogenesis and may be dose-dependent.

[A case of spontaneous cervical carotid artery dissection].

We report a patient with spontaneous cervical internal carotid artery (ICA) dissection. A 46-year-old woman had experienced left neck pain for 10 days. One month later, she was admitted because of the sudden onset of right hemiparesis and left amaurosis, which lasted for 30 minutes. On hospital day 3, the patient experienced the sudden onset of right hemiparesis and total aphasia, which lasted for two weeks. A CT scan failed to reveal any abnormal findings. Cerebral angiograms showed irregular narrowing of the left internal carotid artery distal to the carotid sinus and extending to the base of the skull ("string sign"). Magnetic resonance imaging (MRI) revealed a high signal intensity crescent-shaped mass expanding the wall of the left ICA and narrowing its lumen. SPECT scans showed decreased cerebral blood flow in the left hemisphere. When the symptoms progressed despite-conservative therapy, surgery was performed (STA-MCA anastomosis). Many patients who develop spontaneous ICA dissection show recovery to normal arterial caliber angiographically 1 to 3 months after the onset. Thus, careful monitoring of the clinical course is important and in cases of impending stroke, surgery should be performed immediately.

Simple assessment of cerebral hemodynamics using single-slab 3D time-of-flight MR angiography in patients with cervical internal carotid artery steno-occlusive diseases: comparison with quantitative perfusion single-photon emission CT.

BACKGROUND AND PURPOSE: Visualization of the peripheral arteries on single-slab 3D time-of-flight (TOF) MR angiography (MRA) can reflect blood flow velocity. The velocity in the middle cerebral artery (MCA) may correlate with cerebrovascular reactivity (CVR) to acetazolamide, which can be used to assess hemodynamic impairment. The goal of this study was to compare the signal intensity of the MCA on MRA versus CVR quantified by perfusion single-photon emission CT (SPECT). MATERIALS AND METHODS: The signal intensity of the MCA on single-slab 3D time-of-flight MRA was graded according to the ability to visualize the MCA in 108 cerebral hemispheres of 87 patients with unilateral or bilateral cervical internal carotid artery (ICA) steno-occlusive diseases. SPECT-CVR was also calculated by measuring cerebral blood flow before and after acetazolamide challenge. Ten healthy subjects were studied to obtain control SPECT-CVR values. All subjects provided written informed consent before the study. RESULTS: CVR was significantly lower in cerebral hemispheres with reduced MCA signal intensity than in those with normal intensity (P < .05). When the reduced signal intensity of the MCA on MRA was defined as abnormal, and when a CVR less than the mean--2 SD of healthy subjects was defined as reduced, MRA grading resulted in a 86.2% sensitivity and 69.6% specificity, with 51.0% positive-predictive and 93.2% negative-predictive values to detect reduced CVR. CONCLUSIONS: This simple MRA method can assess hemodynamic impairment with a high negative-predictive value.