Anatomy of the larynx and pharynx: effects of age, gender and height revealed by multidetector computed tomography.

Although oropharyngeal and laryngeal structures are essential for swallowing, the three-dimensional (3D) anatomy is not well understood, due in part to limitations of available measuring techniques. This study uses 3D images acquired by 320-row area detector computed tomography ('320-ADCT'), to measure the pharynx and larynx and to investigate the effects of age, gender and height. Fifty-four healthy volunteers (30 male, 24 female, 23-77 years) underwent one single-phase volume scan (0.35 s) with 320-ADCT during resting tidal breathing. Six measurements of the pharynx and two of larynx were performed. Bivariate statistical methods were used to analyse the effects of gender, age and height on these measurements. Length and volume were significantly larger for men than for women for every measurement (P < 0.05) and increased with height (P < 0.05). Multiple regression analysis was performed to understand the interactions of gender, height and age. Gender, height and age each had significant effects on certain values. The volume of the larynx and hypopharynx was significantly affected by height and age. The length of pharynx was associated with gender and age. Length of the vocal folds and distance from the valleculae to the vocal folds were significantly affected by gender (P < 0.05). These results suggest that age, gender and height have independent and interacting effects on the morphology of the pharynx and larynx. Three-dimensional imaging and morphometrics using 320-ADCT are powerful tools for efficiently and reliably observing and measuring the pharynx and larynx.

Visualization of Lenticulostriate Arteries on CT Angiography Using Ultra-High-Resolution CT Compared with Conventional-Detector CT.

BACKGROUND AND PURPOSE: The newly developed ultra-high-resolution CT is equipped with a 0.25-mm detector, which has one-half the conventional section thickness, one-half the in-plane detector element width, and one-half the reconstructed pixel width compared with conventional-detector CT. Thus, the ultra-high-resolution CT scanner should provide better image quality for microvasculature than the conventional-detector CT scanners. This study aimed to determine whether ultra-high-resolution CT produces superior-quality images of the lenticulostriate arteries compared with conventional-detector CT. MATERIALS AND METHODS: From February 2017 to June 2017, thirteen patients with aneurysms (4 men, 9 women; mean age, 61.2 years) who underwent head CTA with both ultra-high-resolution CT and conventional-detector CT were enrolled. Two board-certified radiologists determined the number of all lenticulostriate arteries on the CTA coronal images of the MCA M1 segment reconstructed from 512 matrixes on conventional-detector CT and 1024 matrixes on ultra-high-resolution CT. RESULTS: There were statistically more lenticulostriate arteries identified on ultra-high-resolution CT (average, 2.85 ± 0.83; 95% CI, 2.509-3.183) than on conventional-detector CT (average, 2.17 ± 0.76; 95% CI, 1.866-2.480) (P = .009) in 16 of the total 26 MCA M1 segments. CONCLUSIONS: Improvements in lenticulostriate artery visualization were the result of the combined package of the ultra-high-resolution CT scanner plus the ultra-high-resolution scanning protocol, which includes higher radiation doses with lower than the national diagnostic reference levels and stronger adaptive iterative dose-reduction processing. This package for ultra-high-resolution CT is a simple, noninvasive, and easily accessible method to evaluate microvasculature such as the lenticulostriate arteries.

Interleukin-8 production via protease-activated receptor 2 in human esophageal epithelial cells.

Interaction between proteases and protease-activated receptor (PAR) 2 has been proposed to mediate inflammatory and immune response in the gastrointestinal tract. Recently, increase in interleukin (IL)-8 in the esophageal mucosa has been associated with the pathogenesis of esophagitis induced by reflux of gastric acids, bile acids or trypsin. The aims of the present study were to determine PAR2 expression in normal human esophageal epithelial cells (HEEC) and to evaluate the mediation of IL-8 production by trypsin-PAR2 interaction in HEEC. Reverse transcription polymerase chain reaction (RT-PCR) and Western blot analysis revealed that PAR2 mRNA and protein were constitutively expressed in HEEC without upregulation by the stimulation with tumor necrosis factor alpha or trypsin. IL-8 was produced in a dose-dependent fashion when cells were stimulated with a PAR2 agonist such as trypsin or SLIGKV-amide. Blocking antibody to PAR2, camostat mesilate (a trypsin inhibitor), p-38 mitogen-activated protein kinase (MAPK) inhibitors or ERK1/2 inhibitors reduced IL-8 production from trypsin-stimulated HEEC. Mutation of the NFkappaB-, AP-1- and NF-IL-6-binding site on the IL-8 gene promoter abrogated the induction of luciferase activities stimulated with trypsin by 100, 80 and 50%, respectively. These results indicate that PAR2 activation in HEEC by trypsin induces NFkappaB- and AP-1-dependent IL-8 production in association with activation of p38 MAPK and ERK1/2, suggesting that esophageal inflammation may be induced by PAR2 activation via reflux of trypsin.

Cerebral hemodynamics in patients with chronic obstructive carotid disease by rCBF, rCBV, and rCBV/rCBF ratio using SPECT.

To evaluate cerebral hemodynamics, 21 patients with chronic occlusion or severe stenosis of the internal carotid or middle cerebral artery with normal or only lacunar infarction on x-ray CT were studied using single photon emission computed tomography (SPECT). We measured rCBV with 99mTc erythrocytes after rCBF with 133Xe, and calculated rCBV/rCBF. rCBF and rCBV of the 25 affected hemispheres were classified as (a) patients with normal rCBF [type I (n = 7) and type II (n = 3)]; (b) patients with decreased rCBF [type III (n = 6) and type IV (n = 9)]. These two groups then could be subdivided according to findings of rCBV, normal, and increased blood volumes. rCBV/rCBF increased as the cerebral perfusion pressure dropped from type I to type III. In type IV, other situations but cerebral autoregulation could be assumed. rCBV/rCBF signifies vascular mean transit time. Type III (high rCBV/rCBF) assumed as the increased OEF, misery perfusion as reported in PET. We propose rCBF, rCBV and rCBV/rCBF using SPECT can be an index for cerebral circulatory reserve.

Calcification of the vertebral artery.

A series of 3,648 computed tomographic (CT) scans was reviewed to determine the incidence of intracranial vertebral artery calcification. Calcification was identified in one or both vertebral arteries in 3.4% and was more frequent in the higher age groups. Skull radiographs demonstrated vertebral artery calcification in only one of 48 patients in whom CT studies showed it. A high correlation was observed between vertebral artery calcification on CT and vertebral artery stenosis on cerebral angiography.

Role of surgery in hypertensive intracerebral hematoma. A comparative study of 305 nonsurgical and 154 surgical cases.

The indications for surgery in hypertensive intracerebral hematoma are still controversial. The reason for this may be: 1) lack of adequate and comparable data in conservative and surgical therapy from the same institution; 2) lack of adequate close follow-up monitoring over an extended period of time; or 3) lack of proper classification of hematomas for comparison of results from different institutions. The authors have treated 459 cases of hypertensive intracerebral hematoma between October, 1975, and July, 1983. The hematomas have been classified according to their mode of extension on computerized tomography. The long-term outcome was assessed on the basis of activity of daily living. Putaminal hematomas were classified as mild, moderate, severe, and very severe. In general, there was no significant difference in outcome between the surgical and nonsurgical cases; however, the outcome in the moderate and severe hematomas was found to be a little better for the surgical cases in some restricted areas. Thalamic and pontine hemorrhages were classified as mild, moderate, or severe. If the hematoma is localized to the thalamus or pons, and if it extends to the midbrain, there is no indication for surgery; however, in patients with moderate hematomas, the prognosis showed a variable outcome, and the indications for surgery were questionable. In cerebellar hematomas, the authors propose that even a hematoma with a diameter greater than 3 cm might show a good outcome with nonsurgical therapy.

Normal perfusion pressure breakthrough syndrome in giant arteriovenous malformations.

The treatment of large, high-flow cerebral arteriovenous malformations is one of the most difficult operations which neurosurgeons encounter because of the complex surgery and the post-operative effects on the brain. We have evaluated 10 patients with large, high-flow AVMs who underwent surgical resection. Patients were investigated with contrast-enhanced computed tomography and magnetic resonance imaging, 1231-IMP single photon emission computed tomography (SPECT) studies of cerebral flow and cerebral vasodilatory function, intraoperative Laser Doppler flowmetry (4 or 10 patients), and conventional angiography. The volume of the arteriovenous malformation nidi ranged from 32.8 to 210.5 cc. SPECT imaging performed on the first post-operative day showed marked hyperperfusion in the brain tissue surrounding the resected nidus, and these regions were normal on images on the 7th post-operative day. Laser Doppler flowmetry showed sudden, and marked increase in CBF immediately following placement of temporary clips on the main feeding artery. Angiograms done on 7-14 days following surgery showed a stagnating artery, fragile vessel, and a prolonged circulation time. Our results indicate that pre- and post-operative SPECT study, especially a dynamic SPECT study done on the first post-operative day, was the most useful examination for ascertaining the post-operative normal perfusion pressure breakthrough.

Clinical usefulness of 3-D CT endoscopic imaging of cerebral aneurysms.

Usefulness of endoscopic imaging of cerebral aneurysms is presented. 3-D luminal images were obtained using a new processing technique which extracts CT numbers in the boundary region between the vessel wall and contrast media filled in the vascular lumen. Clinical application of this technique to complicated large cerebral aneurysms showed that, with this 3-D CT endoscopic imaging, anatomical details of cerebral aneurysms such as the orifice of the aneurysm, intraluminal thrombus, and calcification of the wall could be clearly demonstrated. Using a 3-D imaging method by Helical CT virtual views of various surgical approaches were compared preoperatively. With this technique, not only virtual surgical views of aneurysms and related vasculature, but also surgical views after virtual resection of skull base bone to a desirable extent are freely available. We operated on two large, complicated aneurysms and one broad-based aneurysm after obtaining 3-D CT endoscopic images of the aneurysms. Such information was found to be very useful for determining difficult and complicated cerebral aneurysms and broad-based aneurysms for coil embolization or direct open surgery.

Mechanism and prevention of enlargement or new development of aneurysm following treatment by clipping or coiling.

The mechanisms of cerebral aneurysm recurrence and enlargement were investigated in 11 patients: two with dissecting aneurysms, six with fully grown aneurysms after neck clipping, one with enlarged aneurysm after dome clipping, and two with enlarged aneurysm due to recanalization after GDC coil embolization. We concluded that it is fundamentally important to ensure complete attachment of the internal elastic lamina around the aneurysm neck by precise neck clipping and effective embolization, with accurate positioning of remaining internal elastic lamina.

Evaluation of regional cerebral blood flow changes on perifocal brain tissue SPECT before and after removal of arteriovenous malformations.

In fifteen cases of arteriovenous malformation (AVM), serial examinations of regional cerebral blood flow (rCBF) using single photon emission computed tomography (SPECT) and N-isopropyl-(123I)p-iodoamphetamine were performed. On SPECT images, the nidus was visualized as a focal rCBF defect in all cases preoperatively and seven of these cases had abnormal decreased perfusion areas in the tissues adjacent to the nidus. In five cases, the postoperative SPECT images on the day after surgery revealed an abnormal increased perfusion area adjacent to the nidus and in one case the increased perfusion was accompanied by a massive intracerebral haemorrhage detected by brain computed tomography (CT). In seven cases, postoperative SPECT images showed widespread abnormal decreased perfusion areas in the surrounding tissues and brain CT revealed either intracerebral haemorrhage or significant cerebral oedema. In the other three cases, no remarkable rCBF changes were found in comparison with the pre-operative study. There was a tendency for the preoperative abnormal decreased perfusion area adjacent to the nidus to correlate with the postoperative hyperperfusion and for the postoperative abnormal decreased perfusion area to reflect brain damage.

Effects of calcium antagonists on the erythrocyte membrane.

The effects of dihydropyridine compounds nimodipine, nicardipine and NB818 (isopropyl methyl-6-carbamoyloxymethyl-4-(2,3-dichlorophenyl)-1,4-dihydro-2-methyl- 3,5- pyridine-dicarboxylate) on erythrocyte membranes have been studied. These compounds showed protective effects against hypotonic haemolysis, but not against heat-induced haemolysis. An increase in deformability of erythrocytes by these calcium antagonists was observed using a capillary tube centrifugal method. The erythrocytes showed slight stomatocytosis after 30 min of incubation with calcium antagonists, but did not show significant changes in mean corpuscular volume and ATP levels.

Application of three-dimensional CT angiography (3D-CTA) to cerebral aneurysms.

BACKGROUND: 3D CT angiography (3D-CTA) is a noninvasive imaging modality for cerebral aneurysms. 3D-CTA is helpful in the evaluation of the configuration of the aneurysm, the surrounding vessels, and the inside of the aneurysm dome. Clinical application of this technique in complicated large cerebral aneurysms showed that with 3D-CT endoscopic imaging, anatomical details of cerebral aneurysms such as the orifice of the aneurysm, intraluminal thrombus, and calcification of the wall could be clearly demonstrated. Using the 3D-imaging method with helical CT, virtual views of various surgical approaches can be compared preoperatively. This information was found to be very useful for determining difficult aneurysms for coil embolization or direct surgery including complicated and broad-based aneurysms. METHODS: Helical CT scanners (TOSHIBA X-vigor) are used for intracranial vascular lesions. At present, nearly stereoscopic images at a pixel size of 0.35 x 0.35 x 0.4 mm are obtained by reconstruction under the following conditions: slice thickness, 0.8 mm; couch top speed, 1.0 mm/ sec.; 130 kV; 220 mA; visual field, 18 cm in diameter (11 cm after extension); pitch, 0.4 mm; and opposed beam interpolation. RESULTS AND CLINICAL APPLICATION: By virtual vascular 3D-CT endoscopy, the lumen of the cerebral aneurysm is displayed by the surface rendering method. Its clinical applications include 1) Demonstration of three-dimensional aneurysm morphology, including the dome and the neck region; 2) Preoperative simulation; 3) Confirmation of parent blood vessels flowing into and out of aneurysms and visualization of aneurysmal lumen calcification. Coronal and sagittal sections can demonstrate whether the branches arise from the aneurysm or aneurysmal neck. The limitation of 3D-CTA is in delineating perforating arteries that are less than 1.2 mm in diameter. The problem with virtual vascular 3D-CT endoscopic images is that endoscopic findings in the vascular wall are incomplete because of the partial volume effect and pulsation of the aneurysm and vascular wall. CONCLUSIONS: Helical Scanning-CT (HES-CT) is an excellent noninvasive diagnostic modality for cerebral aneurysm detection. 3D-CT angiography has distinct advantages in evaluating aneurysms and selecting the most appropriate therapeutic modality.

Bilateral giant intracavernous aneurysms. Technique of unilateral operation.

We report a case of bilateral intracavernous giant aneurysms of which the right side was clipped by direct surgery. Our case was a 74-year-old woman who developed bilateral abducens palsy. Computed tomography and angiography showed bilateral intracavernous giant aneurysms. This patient was followed up in the outpatient clinic. She developed headache and right trigeminal neuralgia 2 years later. The trigeminal pain was quite severe and very disturbing to her. Repeat angiography showed an increase in the size of the aneurysms. An operation was carried out after a balloon Matus test monitoring electroencephalogram, somatosensory evoked potential, and clinical symptoms. The cavernous sinus was opened and the aneurysm was clipped. There was no postoperative complication except right ophthalmoplegia which resolved after 3 months. Headache and trigeminal neuralgia also disappeared.

Integrated life-sized solid model of bone and soft tissue: application for cleft lip and palate infants.

The recent development of three-dimensional computed tomography (3D-CT) and laser stereolithography has allowed the creation of life-sized skeletal models. The development of helical CT has enabled us to apply this method to very young children. However, skeletal models alone do not reveal the spatial relationship between soft tissue and bone in complicated craniofacial deformities. We have therefore developed a model that shows both soft and bony tissue by first using CT values that result in a model in which soft tissue is solid and bone is replaced by empty space. The space is then filled with plaster to represent the skeleton. This model also can provide baseline data for evaluating facial growth after surgical repair of clefts. Two infants with cleft lip and palate are presented to illustrate this method of creating an integrated solid model and its applications.

Quantitative measurement of regional cerebral blood flow with I-123 IMP SPECT: a correction of the microsphere model by global extraction between artery and internal jugular vein.

Quantitative measurements of regional cerebral blood flow with N-isopropyl-(Iodine 123)p-iodoamphetamine (I-123 IMP) as a microsphere model were performed in forty cases. The regional cerebral blood flow values obtained with I-123 IMP were slightly underestimated compared with those of Xe-133 inhalation methods (y = 0.90x-2.1, r = 0.85, p less than 0.01). After correction by global extraction (87%) between the artery and internal jugular vein, which was measured in four patients by means of a catheter technique, the underestimation of the values obtained with I-123 IMP was improved (y = 1.0x-2.4, r = 0.85, p less than 0.01). Several problems in the accurate quantitative measurement of regional cerebral blood flow with I-123 IMP are discussed.

Simple and low-cost tele-nuclear medicine conference system with the e-mail protocol.

PURPOSE: Because of the recent innovative growth in computer technology, digital imaging, and the Internet, we can take advantage of these facilities for education and clinical work in nuclear medicine. We developed a tele-nuclear medicine conference system with electronic mail (e-mail) on the Internet. METHODS: Twenty-one physicians (20 radiologists, 1 neurologist), 6 technologists and 2 medical students in six university hospitals (Japan 5, Canada 1), 5 local hospitals in Japan participated in this project. We used digital still cameras (330 k pixels) equipped with a floppy disk drive and 10 x optical zoom to digitize images with JPEG compression (640 x 480 matrix). The images were attached to e-mail messages (containing a brief description of each case). The mail was sent simultaneously to all members on the mailing list. Scintigram and SPECT images as well as other radiological images were sent by e-mail. Reply mails about each case were sent to all members via the mailing list. RESULTS: During a period of 6 months, 18 cases (tumor/infection: 7, bone: 6, cardiovascular: 1, neurology; 3, endocrine: 1) with 144 e-mails (average 5.6/case) were submitted to the conference. The average period of discussion was 15.6 days. The number of attached images was 1 to 9 (average, 4.2/e-mails). JPEG compression rate was 1/10 to 1/20. The quality of the images was good enough for discussion. Some cases required additional images for further discussion. CONCLUSION: Our tele-nuclear medicine conference with an electronic mailing list and digital camera was simple and low-cost. The conference system was useful for education and clinical work.

Minor changes in regional cerebral blood flow revealed by the early distribution of I-123 IMP in brain.

To evaluate the early distribution of I-123 IMP in the brain, 10 dynamic images were obtained in the first 10 minutes after injection using a ring-type SPECT system with a high-sensitivity collimator. In cases of chronic carotid occlusion without brain CT abnormalities, areas of low perfusion were more clearly demonstrated in dynamic images than in static images obtained beginning 20 minutes after injection and continuing for 15 minutes using a high-resolution collimator. In cases of hyperperfusion following infarct or surgery, there was a difference between dynamic and static images in the visualization of hyperemic lesions. The distribution of I-123 IMP in the brain changes gradually, even in the early period after injection, and evaluation of early accumulation is useful for the detection of minor changes in regional cerebral blood flow.

Treatment and results of partially thrombosed giant aneurysms.

Partially thrombosed giant aneurysms are one of the most difficult diseases in the neurosurgical field. We have had 18 of these cases namely, three in vertebral artery, four in basilar artery, four in internal carotid artery, five in middle cerebral artery, and two in anterior communicating artery. Nine aneurysms were clipped, two aneurysms were removed with anastomosis, two cases were treated interventionally, and five cases were treated conservatively because of serpentine and fusiform types of aneurysms in internal carotid artery bifurcation. These conservatively treated patients died due to infarction. When surgery is selected in the thrombosed giant aneurysms, the approach is the most important to secure the neck. Three-dimensional computed tomography angiography was useful to plan the strategy for surgery. If the neck is big enough for placement of a clip, arterial reconstruction is the choice. The reconstruction must be done including an adequate size of the artery because of the thick wall. If the aneurysm neck is too small to reconstruct, aneurysmectomy with anastomosis is one of the choices.

Successful resection of arteriovenous malformations in eloquent areas diagnosed by surface anatomy scanning and motor evoked potential.

Successful resection of cerebral arteriovenous malformations (AVMs) involving the sensorimotor cortex was achieved in 17 cases. The theoretical basis for performing resection of AVMs in eloquent areas is the fact that the brain in and around the nidus about 1 mm in thickness is considered not to be functioning. It is also considered that any center of important function, when an AVM is involved, shifts to the near-by cortex from the original site. Nevertheless, it is critically important to recognize the cortex functioning as sensorimotor centers before and during operation. For this purpose, we have used surface anatomy scanning (SAS) in combination with magnetic resonance angiography. SAS is found to be very useful for the recognition of the topographical relationship between the surface anatomy and AVM. During operation, the motor cortex is identified with motor evoked potential. We have found that, in some cases, the motor center has shifted to the accessory motor cortex. With these information, it is possible to start resection of the lesion from dissection of the main feeders and dissection of the nidus from a silent cortex toward the critical area. Apparent neurological improvements were achieved in 15 of 17 patients treated surgically (88%). With this result, we think that AVMs in eloquent areas can be treated successfully when the surgery is well-designed and well-oriented with the combined use of diagnostic imaging and monitoring. As for control of intraoperative bleeding, careful attention to small but important surgical techniques avoids troublesome bleeding during AVM surgery.

[Classification of intracerebral hematoma (lateral type) on C.T. and its relation to the shift of the lenticulostriate arteries (author's transl)].

Classification of intracerebral hematoma (lateral type) with C.T. was tried. And also, the relationship among the location of the hematoma, the shift of the lenticulostriate arteries and the prognosis of hemiparesis was verified. The results were as follows; 1) The location of the hematoma was classified into four types: 1. anterior type (the hematoma mainly located in the anterior limb of internal capsula). 2. Posterior type (the hematoma mainly located in the posterior limb of internal capsula). 3. lateral type (the hematoma mainly located just below the insula). 4. spread to the all direction type. 2) The lenticulostriate arteries was divided into three portions: L1 portion is the part from the origin at the middle cerebral artery to the knee point, L3 is the part of the distal portion of the lenticulostriate arteries, and L2 portion in the part between L1 and L3 portions. L1 portion was mainly shifted medially in the anterior type of the hematoma. L2 portion was mainly shifted medially in the lateral type of the hematoma. L3 portion was mainly shifted in the posterior type of the hematoma. L1, L2, L3, all portions were shifted medially in the type in which the hematoma spread to all directions 3) The prognosis of the hemiparesis was best in the lateral type of the hematoma, and next in the anterior type. In the posterior type and all spread type, it was worst.