Intracranial electroencephalographic changes in deep anesthesia.

OBJECTIVE: It is well known that electroencephalograms (EEGs) show electrical silence in deep anesthesia as well as brain death. This is the first report on intracranial EEG changes in deep anesthesia. METHODS: We developed a new direct brain monitoring system capable of recording intracranial EEGs. This study included 13 patients with head trauma or cerebrovascular accident under deep anesthesia. RESULTS: The intracranial EEGs showed different patterns of wave activity in depth compared with the cortical surface. In 3 of the cases, the scalp EEG showed a flat tracing at 2.0-2.5% of isoflurane. In two of the cases, the intracranial EEGs showed electrical silence when the scalp EEG was flat. Decreasing the concentration of isoflurane to 1.5%, the intracranial EEG showed single paroxysmal appearance of 'revival' theta waves on the electrocorticogram (ECoG) or electroventriculogram (EVG). The intracranial 'revival' wave was followed by high-voltage burst-waves. In another case, at 2.0-2.5% of isoflurane, the amplitude of the waves was greatest on the EVG. CONCLUSION: There is wave activity difference in the brain depth, which the scalp EEG is unable to show. Intracranial EEGs are able to show the first signs of revival after a nearly flat tracing in deep anesthesia.

Mapping of five subtype genes for muscarinic acetylcholine receptor to mouse chromosomes.

Muscarinic acetylcholine receptors in mammals consist of five subtypes (M1-M5) encoded by distinct genes. They are widely expressed throughout the body and play a variety of roles in the peripheral and central nervous systems. Although their pharmacological properties have been studied extensively in vitro, colocalization of the multiple subtypes in each tissue and lack of subtype-specific ligands have hampered characterization of the respective subtypes in vivo. We have mapped mouse genomic loci for all five genes (Chrm1-5) by restriction fragment length variant (RFLV) analyses in interspecific backcross mice. Chrm1, Chrm2, and Chrm3 were mapped to chromosome (Chr) 19, 6, and 13, respectively. Both Chrm4 and Chrm5 were mapped to Chr 2. Although a comparison of their map positions with other mutations in their vicinities suggested a possibility that the El2 (epilepsy 2) allele might be a mutation in Chrm5, sequencing analyses of the Chrm5 gene in the El2 mutant mice did not support such a hypothesis.

Acute hydrocephalus in posterior fossa injury.

This is the first known report of the use of computerized tomography (CT) scanning to examine acute hydrocephalus in posterior fossa injury. Of the 1802 patients with acute head trauma treated at Funabashi Municipal Medical Center, 53 (2.9%) had suffered injury to the posterior fossa. Of these, 12 patients (22.6%) had associated acute hydrocephalus: nine patients with acute epidural hematoma (AEH) and three with intracerebellar hematoma and contusion (IH/C). There was a significant relationship between cases of AEH with hydrocephalus and supratentorial extension, hematoma thickness of 15 mm or more, and abnormal mesencephalic cisterns. In cases of IH/C, bilateral lesions and no visible fourth ventricle were significant causes of hydrocephalus. According to these results, possible mechanisms of acute hydrocephalus in posterior fossa injury may be as follow: in cases of AEH, hematoma that extends to the supratentorial area compresses the aqueduct posteriorly and causes hydrocephalus; in cases of IH/C, hematoma and contusional lesions may directly occlude the fourth ventricle and cause acute hydrocephalus. Seven patients suffering from AEH with acute hydrocephalus underwent evacuation of their hematoma without external ventricular drainage. In these cases, CT scanning showed that the hydrocephalus improved immediately after evacuation of the hematoma. Two patients suffering from IH/C with hydrocephalus underwent a procedure for evacuation of the hematoma and external ventricular drainage. The authors do not believe that ventricular drainage is necessary in treating posterior fossa AEH. However, both evacuation of the hematoma and ventricular drainage are necessary in cases of IH/C with hydrocephalus to provide the patient with every chance for survival. There was no significant difference in mortality rates when cases of AEH with acute hydrocephalus (0%) were compared with cases of AEH without hydrocephalus (7.7%). The observed mortality rates in cases of IH/C with hydrocephalus and those without hydrocephalus were 100% and 15.4%, respectively; this is statistically significant.

Distribution of referred pain from the lumbar zygapophyseal joints and dorsal rami.

OBJECTIVE: The purpose of this study was to determine the distribution of referred pain from the lumbar zygapophyseal joints (L1/2 to L5/S1) and the medial branches of the lumbar dorsal rami (Th12 to L5) in a large number of patients with chronic low back pain. SETTING: This study was conducted at the pain clinics of Kanto Teishin Hospital and Hannan Central Hospital from March 1994 to May 1996. PATIENTS AND DESIGN: Chronic low back pain patients who underwent zygapophyseal joint injection or radiofrequency facet denervation were studied. Under fluoroscopic control, the joints from L1/2 to L5/S1 were stimulated by injection of contrast medium, and the lumbar medial branches of the dorsal rami from Th12 to L5 underwent electrical stimulation during radiofrequency facet denervation. OUTCOME MEASURES: If the injection or electrical stimulation reproduced the patient's usual pain, the distribution of induced pain was determined, and the sites of induced pain were divided into six areas. RESULTS AND CONCLUSIONS: A total of 71 joints and 91 medial branches were studied in 48 patients. The distribution of referred pain from the L1/2 to L5/S1 zygapophyseal joints, and the medial branches of the dorsal rami from L1 to L5 were similar for each level stimulated, and the overlap of referred pain between each level was considerable.

Development and evaluation of oral reporting system for PACS.

Experimental workstations for oral reporting and synchronized image filing have been developed and evaluated by radiologists and referring physicians. The file media is a 5.25-inch rewritable magneto-optical disk of 600-Mb capacity whose file format is in accordance with the IS&C specification. The results of evaluation tell that this system is superior to other existing methods of the same kind such as transcribing, dictating, handwriting, typewriting and key selections. The most significant advantage of the system is that images and their interpretation are never separated. The first practical application to the teaching file and the teaching conference is contemplated in the Osaka University Hospital. This system is a complete digital system in terms of images, voices and demographic data, so that on-line transmission, off-line communication or filing to any database will be easily realized in a PACS environment. We are developing an integrated system of a speech recognizer connected to this digitized oral system.

[Palinopsia caused by tentorial meningioma. Case report].

Palinopsia is defined as persistence or recurrence of a visual image when the stimulus is no longer present. The authors describe a female patient with a left tentorial meningioma who experienced recurrent visual images. Computed tomography revealed a well demarcated, high-density mass above the left side of the tentorium, but formal field testing revealed no visual field defect. The findings in this case suggest that the palinopsia may have been the result of disordered temporal synthesis of visual experiences.

[Trigeminal neuralgia caused by tortuous vertebrobasilar system--the clinical and imaging features].

Ten (6.8%) out of 146 patients with trigeminal neuralgia (TN) who underwent SPGR-MRI and 3D-TOF-MRA from August 1993 to October 1996, were found to have vascular compression caused by a tortuous vertebrobasilar system (TVBS). They were mostly males, demonstrated left-sided predominance, and had ipsilateral hemifacial spasm, compared with other 52 patients whose offending arteries were either superior cerebellar artery (SCA), anterior inferior cerebellar artery (AICA)or posterior inferior cerebellar artery (PICA). The patients who showed vascular compression by TVBS, presented an artery which compresses and dislocates the rootentry zone (REZ) of the trigeminal nerve, presses the brain stem at REZ and simultaneously compresses the REZ of the facial nerve. In addition, the diameters of the two branches of vertebrobasilar artery were not equal. These features indicate that the atherosclerotic change of the offending artery in TN caused by TVBS is more severe than that caused by SCA, AICA or PICA. This change causes an irregular running of artery which leads a strong compression of the trigeminal nerve REZ and of the brain stem. Consequently, the facial nerve REZ is severely affected leading to the presence of tic convulsif in TN caused by TVBS.

[Identification of offending vessels in trigeminal neuralgia and hemifacial spasm using SPGR-MRI and 3D-TOF-MRA].

We investigated 100 consecutive patients with trigeminal neuralgia (TN) and 53 patients with hemifacial spasm (HFS) concerning the anatomical relationship between the root entry (exit) zone (REZ) of cranial nerve and the offending artery, using spoiled GRASS MRI (SPGR-MRI) and three dimensional-time of fly-MRA (MRA). In 67 of 100 (67%) patiets with TN, this new radiological method, SPGR-MRI and MRA demonstrated the relationship between the fifth cranial nerve root and offending artery causing neurovascular compression (NVC), and in 46 of 53 (87%) with HFS, demonstrated the similar relationship between seventh and eighth nerve complex and offending artery. Microvascular decompression (MVD) was performed in 10 with HFS, and NVC of the REZ of the facial nerve caused by the offending artery was exactly predicted by SPGR-MRI and MRA in 9 (90%). The combination of SPGR-MRI and MRA is very useful for demonstrating NVC as the cause of TN and HFS. On the other hand, we investigated asymptomatic 206 trigeminal and 253 facial nerves about the relationship between their REZ and the surrounding structures using the similar method. The contact of REZ of cranial nerve with surrounding artery is demonstrated in 31.6% of trigeminal nerves and in 22.5% of facial nerves. These results indicate that the contact of REZ of cranial nerve with surrounding artery is not rare in healthy subjects, though causing TN and HFS in particular patients. In this context, we discussed the difference between the contact which is asymptomatic and the compression which is symptomatic.

[Giant intracranial aneurysm visualized by prolonged injection angiography--case report (author's transl)].

A case of giant intracranial aneurysm which almost completely occluded the internal carotid artery and was diagnosed angiographically by prolonged injection technique was reported. A 62-year-old house-wife was admitted to the Department of Neurosurgery of The Asahi General Hospital, complaining of headache, nausea, and left ptosis. Neurological examination revealed left IInd, IIIrd, IVth, and VIth cranial nerve palsy. Films and laminagrams of the skull demonstrated the double floor of the sella trucica. Plain CT scan showed an oval high density area without surrounding low density area in the left middle cranial fossa. A left carotid angiogram revealed almost complete occlusion of the internal carotid artery at the foramen lacerum. Good cross filling through the anterior communicating artery was seen in the right carotid angiogram. Pre-operative diagnosis was pituitary tumor which extended to the middle cranial fossa. Left fronto-temporal craniotomy was performed and the tumor was suspected to be a giant intracranial aneurysm. Post-operative carotid angiogram by prolonged injection technique also showed a blood channel in the aneurysm and a part of the aneurysm. Left carotid ligation was carried out following intracranial surgery and her symptoms were remarkably improved. Apart from left VIth cranial nerve palsy she showed no abnormal neurological findings at discharge. Usefulness of the prolonged injection technique for differential diagnosis of the parasellar tumor was stressed.

[Anterior cerebral artery dissecting aneurysm associated with fibromuscular dysplasia (FMD): a case report].

We have recently encountered a rare case of anterior cerebral artery dissecting aneurysm, presenting cerebral infarction and subarachnoid hemorrhage, associated with fibromuscular dysplasia (FMD). A 50-year-old woman was admitted to our hospital with complaints of headache and hemiparesis. A right carotid angiogram obtained 9 hours after the onset revealed stenosis and slight dilatation in the A1 portion of the anterior cerebral artery. At 12 hours after the onset, the patient fell into a coma. CT scan showed diffuse subarachnoid hemorrhage. An angiogram had revealed aneurysmal dilatation and double lumen in the A1 portion, but, 34 days after the onset, angiogram showed growth of the aneurysm in the A1 portion and stenosis in the A2 and A3 portions. At 38 days after the onset, the trapping of the dilated aneurysm to prevent rerupture was performed. Pathological diagnosis was concluded to be FMD. We concluded that FMD caused stenosis as well as the formation and rupture of the dissecting aneurysm in the anterior cerebral artery.

Isolation of parietal cells from guinea-pig gastric mucosa by a Percoll density gradient.

Isolation of parietal cells from guinea-pig gastric mucosa was performed by density gradient centrifugation using percoll, a new gradient medium composed of colloidal silica coated with polyvinylpyrolidone. The gastric mucosa of the oxyntic gland area was exfoliated, minced and digested with 2.0 mg/ml of dispase and 0.1 mg/ml of collagenase. Dispersed mucosal cells were applied to the percoll density gradient. Parietal cells were fractionated in the layer between 1.04 and 1.06 g/ml in density with purity 80 approximately 90%. For identification of parietal cells staining with tetranitrobluetetrazolium and electron microscopy were used in addition to common staining. The viability of the cells was over 95% assessed by trypan-blue exclusion. The parietal cells obtained responded actively to histamine stimulation when 14C-aminopyrine uptake was used as an functional index. In conclusion, percoll density gradient medium is suitable for yielding isolated parietal cells with both high purity and high viability.

[Thoracic and lumbar sympathetic ganglion block for post herpetic neuralgia].

Of 2,667 patients with herpes zoster who visited our hospital between January 1972 and March 1989, 136 patients whose treatments were started after more than 6 months following the onset were subjects of the present study. Thus we performed a retrospective study of the therapeutic effects of sympathetic ganglion block (using alcohol) on postherpetic neuralgia left untreated for more than 6 months after the onset. After more than 1 year following the onset, the disease was nearly or completely cured in 9 of 37 patients (24%) treated with sympathetic ganglion block with alcohol and in 6 of 34 (17.6%) without the treatment. Thus the patients who underwent sympathetic ganglion block with alcohol tended to show better results. The above findings suggest that, in patients with postherpetic neuralgia in whom the initiation of treatment was delayed, treatment mainly consisting of thoracic or lumbar sympathetic ganglion block using alcohol in combination with antidepressants and antianxiety drugs can greatly improve patients' activities of daily life and that, at present, this method is most effective in relieving postherpetic neuralgia.

[The administration of continuous epidural block under prone position with fluoroscopic guidance].

Continuous epidural block is often used for the treatment of pain. But there have been unsuccessful cases by the routine blind method. We devised a modified method of administering continuous epidural block under prone position with fluoroscopic guidance. The purpose of this study was to evaluate the utility of our modified method. There were 18 cases with pain of lumbar region and 28 cases of thoracocervical region in whom it was not possible to obtain successful control of pain by routine method. By our method, 14 cases (77.8%) with pain of lumbar region and 24 cases (85.7%) of thoracocervical region had effective epidural catheterization. There was no complication. As unsuccessful cases were accompanied with epidural adhesion or psychological disease, they might have no indication for continuous epidural block.

[Treatment of cancer pain with the percutaneous electrocoagulation of spinal nerves].

To our knowledge, this is the first report of high-frequency thermocoagulation applied to the spinal root. We treated 34 patients suffering from cancer pain with this technique. Among these patients, cancer pain occurred due to intrapelvic metastasis in 11 patients, and 13 complained of chest pain due to cancer. Every patient was considered to have good or excellent response when his or her pain score was reduced to 6 points or less from the score before thermocoagulation; 10 points. Based on this criterion, 54.5% and 30.8% of the above-mentioned patients showed good and excellent responses respectively one month after treatment. This technique, therefore, was considered to be effective with less side effects compared with other nerve blocking techniques.

[Six cases of epidural abscess probably caused by epidural block and examination by gadolinium-MRI imaging].

We treated six cases of epidural abscess caused probably by epidural block. Three patients were given only chemotherapy and the other three underwent surgical treatment. Four patients were cured completely, but bilateral paresis in the lower limbs persisted in two patients. The symptoms at onset, laboratory findings, imaging findings including MRI and CT, treatment methods and prognosis were reported. Accelerated blood sedimentation rate, positive CRP results and abnormal findings at the site of the catheter insertion appeared to be important initial signs for the early discovery of epidural abscesses. The route of infection, selection of treatment methods, methods of prevention and examination by Gadolinium-MRI imaging were also discussed.

[Marginal zone lymphoma associated with Sjögren's syndrome and hepatitis C virus infection].

A 64-year-old female was admitted in May 1997, because of salivary gland swelling. Histology of the right parotid gland revealed malignant lymphoma, diffuse medium-sized B-cell type, and she was treated with local radiotherapy and chemotherapy. She was rehospitalized in April 1998, because of recurrence of lymphoma in the stomach and the sigmoid colon. She had splenomegaly and lymphadenopathy (neck and inguinal). Laboratory findings revealed marked elevation of rheumatoid factor and RNA of hepatitis C virus. A diagnosis of Sjogren's syndrome was made by dryness and the histological findings of labial biopsy. Marginal zone B-cell lymphoma mainly consisted of centrocyte-like cells and lymphoepithelial lesions, and CD 20 and IgM-kappa were positive with immunohistochemical staining. Lymphoma involved the gut and spleen. We discuss the correlation of malignant lymphoma with Sjogren's syndrome and HCV infection.

[Endoscopic stage classification of peptic ulcer and characterization of the healing process by proton pump inhibitors].

Proton pump inhibitors are highly effective for gastric acid secretion and have been shown to be superior to histamine H2-receptor antagonists. The superiority of proton pump inhibitors over H2-receptor antagonists was more pronounced in duodenal ulcers. Omeprazole reduced the time required by H2-receptor antagonists the healing of duodenal ulcers by 2/3 to 1/2. On the other hand, unusual endoscopic findings, such as shallow white coat or protrusion of the ulcer floor, were noted in the healing stage of gastric ulcers with H2-receptor antagonists. Whereas these findings were rarely seen with conventional drugs. Histologically, the protrusion was made up granulation tissue consisting of cell infiltration and renewed capillaries with or without regenerated epithelia. These unusual endoscopic findings may be observed in the peptic ulcers treated with proton pump inhibitors.

New ghrelin agonist, HM01 alleviates constipation and L-dopa-delayed gastric emptying in 6-hydroxydopamine rat model of Parkinson's disease.

BACKGROUND: Constipation and L-dopa-induced gastric dysmotility are common gastrointestinal (GI) symptoms in Parkinson's disease (PD). We investigated the novel ghrelin agonist, HM01 influence on GI motor dysfunctions in 6-hydroxydopamine (6-OHDA) rats. METHODS: HM01 pharmacological profiles were determined in vitro and in vivo in rats. We assessed changes in fecal output and water content, and gastric emptying (GE) in 6-OHDA rats treated with orogastric (og) HM01 and L-dopa/carbidopa (LD/CD, 20/2 mg/kg). Fos immunoreactivity (ir) cells in specific brain and lumbosacral spinal cord were quantified. KEY RESULTS: HM01 displayed a high binding affinity to ghrelin receptor (Ki: 1.42 ± 0.36 nM), 4.3 ± 1.0 h half-life and high brain/plasma ratio. 6-OHDA rats had reduced daily fecal output (22%) and water intake (23%) compared to controls. HM01 (3 and 10 mg/kg) similarly reversed the decreased 4-h fecal weight and water content in 6-OHDA rats. Basal GE was not modified in 6-OHDA rats, however, LD/CD (once or daily for 8 days) delayed GE in 6-OHDA and control rats that was prevented by HM01 (3 mg/kg acute or daily before LD/CD). HM01 increased Fos-ir cell number in the area postrema, arcuate nucleus, nucleus tractus solitarius, and lumbosacral intermediolateral column of 6-OHDA rats where 6-OHDA had a lowering effect compared to controls. CONCLUSIONS & INFERENCES: 6-OHDA rats display constipation- and adipsia-like features of PD and L-dopa-inhibited GE. The new orally active ghrelin agonist, HM01 crosses the blood-brain barrier and alleviates these alterations suggesting a potential benefit for PD with GI disorders.