Clinical use of mechanical detachable coils for dural arteriovenous fistula.

Seven dural arteriovenous fistulas were successfully embolized with mechanical detachable coils. Two lesions were located in the transverse-sigmoid sinus, four in the cavernous sinus, and one in the marginal sinus. All lesions were completely occluded on postembolization angiography. No recurrent symptoms appeared during a mean follow-up period of 11 months. Owing to the length and retrievability of the mechanical detachable coils, embolization was quicker and safer, and coils were packed more densely, than is possible with conventional coils. Coil migration was avoided because coils of the appropriate size were chosen before they were placed.

Autologous transplantation of the cervical sympathetic ganglion into the parkinsonian brain: case report.

The authors have reported a clinical trial of an autologous cervical sympathetic ganglion transplanted into the brain of a parkinsonian patient. A 45-year-old woman presented with bradykinesia and a gait disturbance for 8 years under L-dopa treatment. The patient underwent stereotactic transplantation of the right stellate ganglion into the right putamen. She showed marked amelioration of bradykinesia and gait disturbance 1 month after the operation, and she was able to conduct her activities of daily living without requiring L-dopa administration. The patient continued to improve gradually until 3 months after the operation. Two years after surgery, the patient functions independently as a housewife. The right hand tremor, however, became slightly worse after the operation, but it was transient. The patient developed a permanent right-sided Horner's syndrome after resection of the cervical sympathetic ganglion. Taken together with our previous data obtained from animal experiments, this case suggests that the autologous cervical sympathetic ganglion can be donor tissue for neural transplantation in Parkinson's disease.

Diabetic ketoacidosis associated with Guillain-Barré syndrome with autonomic dysfunction.

A 37-year-old woman was admitted in a comatose state, after exhibiting fever and diarrhea. Diabetic ketoacidosis was diagnosed due to an increased blood glucose level (672 mg/dl), metabolic acidosis, and positive urinary ketone bodies. On the fifth hospital day, despite recovery from the critical state of ketoacidosis, the patient suffered from dysphagia, hypesthesia and motor weakness, followed by respiratory failure. Cerebrospinal fluid analysis was suggestive of Guillain-Barre syndrome (GBS). Autonomic dysfunction was manifested as tachycardia and mild hypertension in the acute stage. Marked orthostatic hypotension persisted long after paresis was improved, indicating an atypical clinical course of GBS.

[Intrasellar arachnoid cyst: a case report].

Intrasellar arachnoid cyst is very rare. We report a case of intrasellar arachnoid cyst. A 44-year-old male was admitted for evaluation of his headache and visual disturbance on August 6, 1993. Neurological examination revealed bilateral decreased visual acuity and visual field defect. Endocrinological examination showed panhypopituitarism. Other neurological findings were normal. X-ray film of the skull showed a ballooning dilation of the sella turcica with thinning of the sellar floor. CT scan showed a cystic lesion with CSF-density occupied the sella. After intravenous administration of contrast medium, the cyst showed no enhancement. MRI showed the intrasellar mass had the same characteristics as the surrounding subarachnoid space. Bilateral carotid angiographies demonstrated that the carotid siphons were stretched and displaced laterally, and the A1 portions of the anterior cerebral arteries were raised. We made a diagnosis of intrasellar cystic lesion. On August 18, the sella turcica was opened via the transsphenoidal rhinoseptal approach. The cyst contained CSF-like fluid, and a part of the cyst wall was resected. The cavity was filled with Gelfoam and the sellar floor was repaired with bone flap. Postoperatively, the patient's visual disturbance improved, but diabetis insipidus appeared and required hormonal replacement. The patient was discharged on September 27 with improvement of visual acuity and visual field. Histological examination demonstrated that the cyst wall consisted of thick arachnoidal cells with fibrous connective tissue. The arachnoidal cells with oval nuclei was stained with epithelial membrane antigen. Symptoms, signs and radiological findings of intrasellar arachnoid cyst are similar to those of various sellar lesions including pituitary adenoma, craniopharyngioma, empty sella, Rathke's cleft cyst, epidermoid et al.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of acute myeloblastic leukemia associated with multiple intracerebral hematomas].

A case of acute myeloblastic leukemia associated with multiple intracerebral hematomas is presented. A 19-year-old woman with a two week's history of mild fever suddenly lost consciousness, and was afflicted right severe hemiparesis, left mild hemiparesis and motor aphasia. A CT scan revealed bilateral thalamic hyperdense lesions and paraventricular small hematoma in the right hemisphere. Hematology showed marked leukocytosis (450,000/mm3), mild anemia and no coagulopathy including disseminated intravascular coagulation syndrome. Cytology showed myeloblasts with positive stain in peroxidase and negative in esterase both in cerebrospinal fluid and blood. These findings indicated M 1 type, myeloblastic leukemia without maturation, according to FAB (French-American-British Co-operative group) classification. CT scan on the second day demonstrated expansion of the hematoma in the right thalamus, and nine brand-new small hematomas in different locations. The patient deteriorated into brain death soon after this examination. The pathology of this case was supposed to be "hyperleukocytosis", which is defined as a leukocyte count greater than 100,000/mm3. Severe leukostasis due both to dense leukocytes and lack of mobility of the myeloblast brought about an increase in permeability because of local impairment of nutrition to the walls of the vessels. As a result, the following histological changes occurred: 1) cellular exudation into Virchow-Robin space, 2) the appearance of leukemic nodule, admixtures of leukemic cells and erythrocytes, 3) mechanical compression of the capillaries and venules by the enlarging mass of the leukemic nodules. CT scan showed these characteristics as follows: 1) multiplicity, 2) small-size, 3) cerebral hemisphere, especially in white matter.(ABSTRACT TRUNCATED AT 250 WORDS)

[Intraarterial injection of low molecular weight dextran and urokinase for acute cerebral infarction].

Strategic recanalization of the occluded cerebral vessels has shown promise as a therapy for embolism and thrombosis in the acute stage. A single-dose of urokinase (UK) administered by intravenous and intraarterial routes was usually designed to restore patency of the infarct-related arteries and reperfuse the area of infarction. However, thrombolytic agents which have been available to date may lack resoluvability, limiting the amount of doses, because overdosage may induce hemorrhagic complication. This newly-designed therapy, intraarterial injection of UK-low molecular dextran (LMWD) complex was introduced in order to overcome the danger shown in the previous study. A high-resolvent allows cut-down of urkinase doses. Patients with acute cerebral infarction were selected for treatment with the resolvent if they satisfied the following conditions: 1) up to 79 years old without serious systemic diseases, 2) less than 12 hours from the onset, 3) better than the score of 8 in GCS, 4) no abnormality in CT scan, 5) apparent neurological deficit and 6) responsible pathology in angiography. LMWD of 15ml, UK of 240000IU and 15ml saline-complex was injected as one course at 2.0-2.5ml/min for 11 cases. Recanalization was observed in seven cases of embolism, and lack of reperfusion in five cases of thrombosis. The minimum effective dose was determined as 480000IU of UK in two courses. In terms of time lag from the onset, six hours may be the inferior limit, within which five of six cases (83%) succeeded in the recanalization.(ABSTRACT TRUNCATED AT 250 WORDS)

Ventricular arrhythmias in children: the validity of exercise stress tests for their diagnosis and management.

One hundred ninety-six children ranging in age from 4 years to 15 years with premature ventricular contraction (PVC) on a resting electrocardiogram (ECG) underwent exercise tests and 29 of them were found to have significant ventricular arrhythmias. They included 8 patients with 2 PVC's in row, 8 patients with 3-4 PVC's in row, and 13 patients with more than 5 PVC's in row (ventricular tachycardia: VT). These 29 patients were evaluated with exercise tests by two-step exercise ECG (TSE) and by treadmill (TM), and with 24 hour continuous ECG monitoring (Holter monitoring). 141 ECG's, 77 TSE's, 77 TM's and 46 Holter monitoring were obtained in total, and the incidence of the each study revealing findings compatible with the final diagnosis was 3%, 15%, 51% and 26%, respectively. For detection of 2 PVC's in row, the sensitivity of TSE and TM was not different, but for picking up 3-4 PVC's in row and VT, TM was significantly superior to TSE. Among the VT patients, there were a few cases in whom neither TM nor Holter monitoring alone was sufficient to confirm the diagnosis. Children with symptoms suggestive of ventricular arrhythmias should be carefully evaluated with a combination of exercise tests and Holter monitoring.

Factors Leading to and Treatment of Aneurysmal Perforation during Coil Embolization. Analysis of 105 Consecutive Cases.

SUMMARY: It is important to know the characteristics of aneurysms that tend to cause perforation and treatment of these perforations to reduce the morbi/mortality of the endovascular treatment for intracranial aneurysms. Factors leading to aneurysmal perforation were analyzed from the view points of aneurysmal status (ruptured or unruptured), size and direction of aneurysmal dome from the parent artery and treatment of perforation during GDC embolization was discussed in 105 consecutive cases. Perforation occurred in three small aneurysms (less than 3 mm in diameter or depth) where the direction of the dome is the same as that of microcatheter advancement. Perforation occurred when a microcatheter was advanced to counteract catheter recoil caused by coil deployment. Haemorrhage occurred in all cases immediately following microcatheter and coil perforation into the subarachnoid space. In all cases, bleeding was controlled by deploying the coil so that it extended from the subarachnoid space back into the intraaneurysmal cavity. In two cases, surgical clipping was required to treat the incompletely obliterated aneurysm. No additional permanent neurological deficit occurred as a result of any of the three perforations. Special care should be taken during the embolization of small aneurysms (less than 3 mm in minimal diameter) where, owing to the shape of the lesion, or fixation of a microcatheter by the stent strut, the antegrade force of the canulating microcatheter is transmitted directly toward the aneurysm dome.

Myocardial infarction and left coronary ostial stenosis in infancy simulating anomalous origin of the left coronary artery. A case report.

A case of a 3-month-old male infant with myocardial infarction due to left coronary ostial stenosis is presented. Clinically it was quite similar to anomalous origin of the left coronary artery. Postmortem examination revealed quite narrow left coronary ostium and myocardial infarction with aneurysm of the left ventricular apex.

Endovascular treatment for vertebral dissecting aneurysm presenting with subarachnoid hemorrhage.

We report results and problems of the endovascular treatment in 12 cases of intradural vertebral dissecting aneurysm presenting with subarachnoid hemorrhage. There were four complications related to interventional procedure and conventional angiography. In three patients (25%), VDAs ruptured immediately after injection of contrast media or hypertension during the interventional procedure, which caused respiratory arrest. In a case of bilateral VA dissection (8%), after proximal VA occlusion had been performed for unilateral VDA, contralateral dissection extended to the basilar artery resulting in brain stem infarct. We suggest that the incidence of rebleeding of VDA during angiography and embolization is higher than that of usual saccular aneurysms. Careful injection of contrast media and strict blood pressure control seems to be more important to prevent rebleeding in VDAs than intracranial saccular aneurysms. Since unilateral VA occlusion may extend contralateral dissection in a case of bilateral VA dissection, it is necessary to check contralateral VA dissection before VA occlusion.

Measurement of the intracranial arterial wedge pressure in cases of acute cerebral arterial occlusion to determine the indication of intraarterial thrombolytic therapy.

SUMMARY: Wedge pressure of the occluded major cerebral artery (distal pressure beyond the occlusion) was measured to estimate the residual cerebral blood flow in thirteen patients with acute ischemic stroke. There existed the relationship that patients with higher wedge pressure tolerated longer ischemic insults than those with lower wedge pressure. Wedge pressure is measured with minimum time loss before starting thrombolytic therapy and may be a good indicator to estimate the brain tissue reversibility.

[Thallium-201 myocardial imaging in patients with congenital heart disease following open-heart surgery].

Thallium-201 myocardial imaging was performed for 77 patients with congenital heart disease to evaluate myocardial damage following open-heart surgery. There were 23 patients with ventricular septal defects, 33 with tetralogy of Fallot, 12 with atrial septal defects, and nine with other diseases. The imaging results were compared with the angiographic and electrocardiographic findings. Patchy perfusion defects or images of poor thallium uptake were noted in five of 77 patients, among whom four had accompanying serious ventricular arrhythmias. This suggested a close correlation of the post-operative ventricular arrhythmias with myocardial damage. For 20 of 77 patients, vents were inserted through the left ventricle, and for the remaining 57 through the left atrium. Perfusion defects were found at the apex in three, and left ventriculography showed a paradoxical motion of the apex in five in patients whose vents were inserted through the left ventricle. Sensitivity and specificity in detecting myocardial damage of the apex were 60% and 98%, respectively. In one case, myocardial infarction was demonstrated immediately after the repair of the ventricular septal defect. Myocardial imaging was useful in evaluating the infarcted area and for follow-up study. Thus, thallium-201 myocardial imaging was regarded useful for assessing myocardial damage following open-heart surgery in congenital heart disease patients.

Clinical Results and Problems in Embolization for Intracranial Aneurysms using Electrically Detachable Coils.

SUMMARY: Nineteen patients with intracranial aneurysm were treated using electrically detachable coils (GDC or IEDC) and angiographic results and complications were assessed. In 18 aneurysms treated by endosaccular occlusion, 11 (61%), 3 (17%) and 4 (22%) resulted in complete occlusion, neck remnant and dome filling, respectively. Neither haemorrhagic nor thromboembolic complications occurred in 19 patients. Embolization using electrically detachable coils seemed to be a safe and useful procedure without complications, but we should give attention to avoiding complications and incomplete occlusion in particular in a case of 1) wide-necked, 2) small (< 3 mm) or 3) complex- shaped aneurysms.

[Two-dimensional echocardiographic diagnosis of congenital malformations of the aorta in infants and children (author's transl)].

Two-dimensional echocardiographic studies were performed in 23 patients with coarctation of the aorta, 5 with interruption of the aortic arch, 6 with supravalvular aortic stenosis, 3 with truncus arteriosus, 2 with anomalous origin of the right pulmonary artery from the ascending aorta and 2 with aorto-pulmonary septal defect. The diagnosis was confirmed in each patient by surgery and/or cardiac catheterization and angiography. Visualization of the junction of isthmus and the descending aorta was possible in 18 of 23 patients with coarctation by two-dimensional echocardiography. In 13 patients correct diagnosis was obtained prospectively and in 2 patients coarctation was detected retrospectively. In only one of the 5 patients with interruption correct diagnosis was obtained and in 3 patients it was difficult to differentiate interruption from coarctation. In 5 of the 6 patients with supravalvular aortic stenosis, visualization of the area of obstruction was possible to two-dimensional echocardiography. In 2 of the 3 patients with truncus arteriosus, in whom none of the 2 had anomalous origin the right pulmonary artery from the ascending aorta and one of the 2 had aorto-pulmonary septal defect, correct diagnosis was obtained prospectively by two-dimensional echocardiography. Two-dimensional echocardiography may offer a useful noninvasive method for the direct visualization of aortic obstructive lesions and aortic malformations.

[Two-dimensional echocardiography of coronary artery in Kawasaki disease (MCLS): detection, changes in acute phase, and follow-up observation of the aneurysm (author's transl)].

Two-dimensional echocardiography (2-D echo) was performed before coronary angiography in 213 patients (pts), 4 months to 12 years old, with a history of Kawasaki disease (MCLS). In 10 pts, 2-D echo was performed almost everyday during acute phase. In 23 pts, coronary artery aneurysms were followed up for more than 6 months by 2-D echo. In 32 of 213 pts, the presence of coronary artery aneurysms (9 pts with left, 4 pts with right and 19 pts with both coronary arteries) were proved by coronary angiography. The correct diagnosis was achieved prospectively by 2-D echo in 26 of 32 pts with coronary artery aneurysm (in 24 of 28 pts with left and 15 of 23 pts with right coronary artery aneurysm). In all 10 pts with acute phase of MCLS, an increased echocardiographic density around the coronary artery and of the coronary artery itself continued from the 4th or 6th day to the 10th day or near the second month of the illness. The findings were considered due to acute perivasculitis and vasculitis in the coronary artery. In 5 of 10 pts, the dilatation of coronary artery was demonstrated on about 6th day of the illness and in 3 pts was transient, but in other 2 pts the dilated coronary arteries grew up aneurysms on the 9th and 13th day of the illness. In 23 pts with coronary artery aneurysm followed up by 2-D echo for more than 6 months, 18 pts were started to observe within 6 months and 5 pts beyond 1 year after the onset of illness. In the former, the size of aneurysm was markedly reduced in 7, slightly reduced in 6, and did not change in 5 pts. On the other hand, it did not change in all the 5 pts of the latter. This study suggests that 2-D echo is very useful to diagnose noninvasively coronary artery aneurysm in pts with the history of MCLS and to detect and follow-up it in acute phase.