Disease duration: the key to accurate CSF tap test in iNPH.

OBJECTIVES: The cerebrospinal fluid tap test for idiopathic normal pressure hydrocephalus (iNPH) is one of the good predictors of the shunt treatment, although this test has a low sensitivity. We aimed to identify key parameters that could be used to improve this sensitivity. MATERIALS & METHODS: During 2010-2011, we recruited and then followed 93 patients with possible iNPH for 12 months after shunt. Among them, 82 patients were finally enrolled in this study. The modified Rankin Scale, iNPH grading scale, and several quantitative measurements were evaluated at entry, after the tap test, before and after shunt. Area under the receiver-operating characteristic curves (AUCs), sensitivities, and specificities of the tap test for predicting shunt effectiveness were calculated for each measurement. They were additionally assessed after stratification by disease duration since the initial presentation of iNPH symptoms. RESULTS: The gait disturbance on the iNPH grading scale had the highest accurate scale at the tap test for predicting effectiveness 12 months after shunt: AUC 0.74, sensitivity 56.5%, specificity 91.7%. This AUC increased to 0.76, 0.91 and 0.94 in the subgroup of disease duration <24, <12, and <6 months, respectively. The sensitivity and specificity of the gait disturbance on the iNPH grading scale in the subgroup of <12 months' duration were 92.3% and 90.0%. CONCLUSIONS: The shorter period of clinical symptoms, for example, <12 months, made the tap test sufficiently accurate examination for predicting improvement 12 months after shunt surgery. The findings imply that the tap test should be applied to patients being considered for shunt surgery as soon as possible.

Structure-activity relationships of triterpenoid derivatives extracted from Gymnema inodorum leaves on glucose absorption.

The leaves of Gymnema inodorum (GI) have been known to be effective for some diseases including diabetes mellitus, rheumatic arthritis and gout. The crude saponin mixtures extracted from GI leaves inhibited glucose absorption in the isolated intestinal tract and suppressed the increased blood glucose in rats. In this study, we examined the relationship between chemical structure and pharmacological activity of the four components from GI leave extracts (GiA-1, GiA-2, GiA-5 and GiA-7). These components were the derivatives of (3beta,4alpha,16beta)-16,23,28-trihydroxyolean-12-en-3-yl-beta-D-glucopyranosiduroic acid. GiA-2, GiA-5 and GiA-7 that have suppressive effects on the high K+-induced contraction, an increase in deltaPD and the increased blood glucose level in the glucose tolerance test have -H at the 21st position and -CH2OH at 4beta of aglycon. On the other hand, GiA-1 that does not have any effects on the three parameters mentioned above has -H at the 21st position and -CH3 at 4beta of aglycon. In conclusion, it is suggested that the inhibitory effect of triterpenoids in Gymnema leaves on glucose absorption from the intestinal tract relies on -CH2OH at 4beta.

Surgery or gamma -knife for the treatment of arteriovenous malformations?

Decision making for either surgery or gamma-knife for the treatment of arteriovenous malformations (AVMs) cannot be uniform. The skill of the neurosurgeon in operating on AVMs is now being compared with that of the gamma-knife. The decision varies from case to case and is to be taken by the neurosurgeon. This report presents three cases in which such decision making was not easy. Case 1 was a non-ruptured cingulate AVM of 2.5 cm diameter in the cingulate cortex. The operative field was anticipated to be very narrow between the parietal bridging veins. Case 2 was a tiny ruptured AVM in the speech-motor area which was buried underneath the cortex. Case 3 was a large ruptured thalamo-stiriate-capsular AVM with feeders from the anterior and posterior choroidal arteries. All cases were operated without serious morbidity. A combination of pre-operative intravascular surgery (cases 1 and 3) or postoperative gamma-knife (case 3) was adopted. In conclusion, there is no unitary rule to decide on surgery or gamma-knife for the treatment of AVMs. It depends on what good or harm the responsible surgeon or the gamma-knife does.

Jugular bulb diverticulum associated with lower cranial nerve palsy and multiple aneurysms.

BACKGROUND: Jugular bulb diverticulum is a rare condition that has never been reported in association with lower cranial nerve palsy. CASE DESCRIPTION: A 54-year-old woman developed acute swallowing disturbance and hoarseness. Neuroradiological examinations demonstrated a jugular bulb diverticulum as well as unruptured internal carotid and basilar tip aneurysms on the same side. Laboratory data for both serum and cerebrospinal fluid were normal. Steroids were given, and the cranial nerve palsy disappeared within 1 month. The aneurysms were successfully clipped. During the follow-up period of more than 1 year, the patient has done well and has no neurological deficit. CONCLUSION: This is the first reported case of jugular bulb diverticulum associated with a lower cranial nerve palsy and multiple aneurysms. We recommend close observation of patients with this condition regardless of its clinical presentation.

Orbitozygomatic approach by transposition of temporalis muscle and one-piece osteotomy.

BACKGROUND: A more simplified and easier technique for the orbitozygomatic approach is sought. We have developed a new modification to fully expose the temporal base before using one-piece craniotomy. METHODS: By transposing the temporalis muscle underneath the zygomatic arch before osteotomy, the temporal base and the inferior orbital fissure can be fully exposed. Craniotomy is made in one piece with the frontotemporal and orbitozygomatic bone together by using a high-speed drill. RESULTS AND CONCLUSIONS: Osteotomy was easy and the cosmetic result was satisfactory. This technique also allows better access to the subtemporal region without removing the zygomatic arch.

A case of sigmoid sinus dural arteriovenous fistula after treated cavernous dural arteriovenous fistula.

SUMMARY: Transvenous embolization has been recommended recently as the primary treatment for symptomatic cavernous dural arteriovenous fistula (dural AVF). We present a case of sigmoid sinus dural AVF which developed after transvenous embolization of cavernous dural AVF. A 43-year-old man was admitted to our hospital because of left conjunctivill chemosis, exophthalmus and abducens nerve palsy. Cerebral angiograms showed left cavernous dural AVF fed by the bilateral internal and external carqtid arteries and draining into the enlarged left superior ophthalmic vein. Transfemoral approach in the cqvernous sinus via inferior petrosal sinus (IPS) was difficult because of the occlusive change of IPS. Then, direct canulation of the left superior ophthalmic vein and transvenous embolization using interlocking detachable coils (IDC) were performed. Dural AVF and clinical symptoms were disappeard rapidly after embolization. Six months later, follow-up cerebral angiograms showed development of a dural AVF in the left sigmoid sinus. The pathogenesis of dural AVF remains unclear. We suggest that injury to the sinus wall during endovascular procedures may have provoked the development of dural AVF in our case. Clinical and angiographical follow-up are important.

Suppression of glucose absorption by extracts from the leaves of Gymnema inodorum.

Gymnema sylvestre (GS) is one of the Asclepiad strains that grows in South-east Asia. Their therapeutic effects for treating diabetes mellitus, rheumatic arthritis and gout have been well known for a long time. However, the problem is that GS suppresses sweetness and tastes bitter. For this study, we chose Gymnema inodorum (GI) instead of GS, since it has an advantage that it does not suppress sweetness nor is it bitter in taste. In this paper, effects of glucose availability of some saponin fractions (F-I to F-IV) extracted from GI leaves, which were obtained by high-performance liquid chromatography were studied on a high K(+)-induced contraction of guinea-pig intestinal smooth muscle, O2 consumption on guinea-pig ileum, glucose-evoked transmural potential difference (delta PD) of guinea-pig everted intestine and blood glucose level in glucose tolerance tests on rats. The extracts of GI leaves suppressed the intestinal smooth muscle contraction, decreased the O2 consumption, inhibited the glucose evoked-transmural potential, and prevented the blood glucose level. Our studies suggest that the component of GI inhibits the increase in the blood glucose level by interfering with the intestinal glucose absorption process.

[Objective evaluation of selective peripheral denervation for spasmodic torticollis].

The authors evaluated the results of selective peripheral denervation (SPD) of posterior rami of the cervical spinal nerves and/or the accessory nerve for spasmodic torticollis. Five patients underwent seven operations in total and the results were evaluated with the modified Tsui's score which was used in the clinical trial of botulinum toxin (BTX) for torticollis in Japan. The preoperative score was 10.8 +/- 2.2 (mean +/- S.D.) and the postoperative score was 1.4 +/- 1.7. The score changes indicated the effects of the operation as "excellent" in four cases and "good" in one case. These results indicate that SPD is superior to BTX in terms of control of symptoms in spasmodic torticollis. After the initial operation, however, two patients showed the so-called "mole-hitting game phenomenon" in which normal muscles develop abnormal contraction after denervation of abnormal muscles. This forced us to perform the second operations. Although this phenomenon was first described in botulinum toxin treatment, this is probably the first report in surgically denervated cases.

Suppression of glucose absorption by some fractions extracted from Gymnema sylvestre leaves.

Extracts containing gymnemic acids, which were extracted from the leaves of Gymnema sylvestre (GS) as nine fractions, were evaluated for their effects on a high K(+)-induced contraction of guinea-pig ileal longitudinal muscles, on glucose transport mediated by the difference of glucose-evoked transmural potential difference (delta PD) in the inverted intestine of guinea-pig and rat, and on blood glucose in rat. Among nine fractions obtained by high performance liquid chromatography from the extract, f-2 and f-4 strongly suppressed the high K(+)-induced contraction of the ileal muscle, f-3 and f-5 did so moderately, and f-8 and f-9 did so weakly, whereas the other fractions did not affect it. The degree of suppression of high K(+)-induced contraction by f-2 at 74% was almost the same as that of f-4 at 67%, at concentrations of 0.1 mg/ml. The suppressed contraction by f-2 or f-4 was recovered by adding 5.5 mM pyruvate. The delta PD increased by 5.5 mM glucose in the inverted intestines of guinea-pig and rat were equally suppressed by 0.1 mg/ml of f-2 or f-4 to 40%. In a rat sucrose tolerance test, f-2 and f-4 suppressed the elevation of blood glucose level. Both f-2 and f-4 suppressed the contraction of guinea-pig ileal longitudinal muscle, interfered with the increase in delta PD induced by glucose in the inverted intestines of guinea-pig and rat, and inhibited the elevation of blood glucose level. In conclusion, it is suggested that some of the extracts containing gymnemic acids from GS leaves suppress the elevation of blood glucose level by inhibiting glucose uptake in the intestine.

[Inhibitory effects of glucose utilization by gymnema acids in the guinea-pig ileal longitudinal muscle].

Two substances identified as ((3 beta, 4 alpha, 16 beta, 21 beta, 22 alpha)-21-tigloxy-16, 22, 23, 28-tetrahydroxyolean-12-en-3-yl-beta D-glucopyranosiduronic acid) (GA1) and ((3 beta, 4 alpha, 16 beta, 21 beta, 22 alpha)-21-(2-methylbutyroxy)-16, 22, 23, 28-tetrahydroxyolean-12-en-3-yl-beta-D-glucopyranosiduronic acid) (GA2) identified among the gymnemic acids are triterpene glycosides extracted from Gymnema sylvestre leaves. We examined the effects of GA1 or GA2 on high K(+)-induced contraction in the guinea-pig longitudinal muscle. A sustained muscle contraction induced by hyperosmotically added 65.4 mM KCI (H-65K+) was suppressed by GA1 or GA2 (7.7 x 10(-5) M). Simultaneous measurements of reduced pyridine nucleotide (PNred) or oxidized flavin protein (FPox) by the fluorescence technique and of contractile force revealed that GA1 and GA2 reduced the increase of PNred fluorescence and contractile force induced by H-65K+, whereas FPox fluorescence induced by it further increased. Reduced muscle contraction induced by GA1 or GA2 was restored by 5.5 mM pyruvate. Simultaneous measurements of intracellular Ca2+ [Ca2+]1 level and contractile force indicated that [Ca2+]1 level, which increased by H-65K+, hardly changed with GA1 and GA2. In summary, both GA1 and GA2, which are among the gymnemic acids, suppressed high K(+)-induced contraction in the guinea-pig ileal longitudinal muscle. The difference between these two gymnemic acids was not significant. The inhibitory effect of GA1 and GA2 on smooth muscle were assumed to be a result of inhibiting glucose uptake, which is an energy source of the muscle, whereas the inhibitory mechanisms were probably not mediated by Ca2+.

Primary large choroid plexus papillomas in the cerebellopontine angle: radiological manifestations and surgical management.

Two cases of primary choroid plexus papilloma originating in the cerebellopontine angle (CPA) are reported. Both papillomas were encapsulated and strongly adhering to a choroid plexus tuft protruding from the foramen of Luschka. Successful removal of the tumour was achieved in each case. Surgical strategy, neuroradiological manifestations, and the differential diagnosis are discussed.

Transcranial magnetic stimulation excites the root exit zone of the facial nerve.

The actual site of excitation of the facial nerve by transcranial magnetic stimulation was investigated in five patients with hemifacial spasm who underwent microvascular decompression. The facial nerve was stimulated preoperatively and intraoperatively by transcranial magnetic stimulation and intraoperatively by electrical stimulation at its root exit zone with a minimum of surgical invasion of the facial nerves. The onset latency of compound muscle action potentials recorded from the nasalis muscle was 5.06 +/- 0.44 ms by magnetic stimulation and 5.08 +/- 0.43 ms by electrical stimulation. The latency difference was 0.06 +/- 0.08 ms. Therefore, transcranial magnetic stimulation was basically the same as electrical stimulation in onset latency. From this study, it appears that the root exit zone of the facial nerves is stimulated by transcranial magnetic stimulation.

Coexistence of extracranial internal carotid artery aneurysm and multiple intracranial aneurysms--case report.

A rare case of extracranial internal carotid artery (ICA) aneurysm coexisting with intracranial multiple aneurysms in a 64-year-old female is reported. The three intracranial aneurysms were clipped uneventfully by two-stage craniotomies. The extracranial ICA aneurysm at the infratemporal region was excised through a high cervical route and ICA was reconstructed by an end-to-end direct anastomosis. Ours is the first case reported of extra- and intracranial aneurysms surgically treated successfully.

[Transorbital penetrating brain injury].

Transorbital penetrating brain injury is rare during this time of peace. In our paper, we reported seven cases of these injuries and discussed the mechanism and treatment of intracranial complications. Transorbital penetrating brain injuries were caused by thin, long and relative hard objects such as chop-stick (case 3), pencil (case 6), bamboo stick (case 1, 2, 7) and a piece of metal (case 4, 5). CT scan, MRI and angiography demonstrated a large variety of intracranial complications. For instance, intracerebral hematoma, cerebral contusion, intraventricular hemorrhage, pneumocephalus, brain stem injury and carotid cavernous sinus fistula. We had no case of infectious complications such as meningitis and brain abscess. If the direction of the injuring object runs parallel to the orbital roof, it penetrates the cranial cavity commonly via the superior orbital fissure or the optic canal, which routes provide direct access without bone fracture. This direction will cause critical intracranial complications such as CCF or brain stem injury. If the injuring object runs upward and across the orbital roof which has thin bone and therefore offers little resistance, the frontal lobe will be easily damaged, and it will cause intracerebral hematoma. But the prognosis for this type of injury is not so poor because we can easily remove the hematoma and the foreign body. With our treatment policy of "pull and see", all our cases but one recovered well. The one exception was a case in which a large intracerebral hematoma was over-looked in an ophthalmological clinic. This patient died. Nowadays, CT scan and MRI give clear information about the anatomical location of injuring objects and intracranial complications.(ABSTRACT TRUNCATED AT 250 WORDS)

[Direct surgical management of aneurysms in the cavernous sinus: a report of 5 cases].

Five patients with aneurysms in the cavernous sinus were treated by direct surgical approach. Two small aneurysms were located in the C3 segment, one small aneurysm was on the primitive trigeminal artery (PTA), and the last two aneurysms were giant ones. The three small aneurysms were discovered incidentally by angiography and the two giant aneurysms presented oculomotor palsy. After ordinary fronto-temporal craniotomy, the two C3 aneurysms were treated through an intradural approach, and the PTA aneurysm and the two giant aneurysms were treated through combined epi- and subdural approach. The three small aneurysms were clipped and the two giant aneurysms were trapped with the reconstruction of ICA by saphenous veins. In all cases the aneurysms were excluded postoperatively, but in one giant-aneurysm case (Case 5) the bypass was occluded postoperatively, but the patient had no permanent neurological deficit. The four patients developed third nerve palsy and one developed fourth nerve palsy which resolved within 3 to 6 months. In one C3-aneurysm case (case i) the patient had loss of vision due to much packing in the medial side of the ICA. All patients were discharged and returned to their usual life. Three cases (case 2, 4, 6) are presented here and the problems of direct surgical management of aneurysms in the cavernous sinus are discussed with the related literature.

[Intraoperative ABR monitoring during cerebello-pontine angle surgery].

Intraoperative auditory brainstem response (ABR) monitoring was performed in 27 patients undergoing C-P angle surgery (12: hemifacial spasm, 10: trigeminal neuralgia, 2: glossopharyngeal neuralgia, 3: C-P angle tumor, 2 epidermoid, 1 meningioma). Because of the introduction of this method, no patient suffered from postoperative hearing disturbance in this series. During C-P angle surgery, the wave V of ABR changes according to the retraction of the cerebellum and the manipulation of the eighth cranial nerve. Many authors have discussed this change, however the timing and the mechanism of disappearance of wave V is unclear. Accordingly, the authors discussed the correlation between the prolongation of wave V latency and its amplitude. The wave V amplitude was measured from the positive peak of wave V to the next negative peak. Then, the correlation between the prolongation of wave V latency and its reduction ratio (%) of amplitude was represented as a parabola. The wave V reduces its amplitude when the prolongation of the latency is from 1.5 ms to 2.0 ms. Once the prolongation of the latency is over 1.5 ms, the amplitude of wave V seems to be reduced suddenly, because it takes over 1'30'' to finish each record. But the authors demonstrated the gradual reduction of the amplitude of wave V in Figure 3. As mentioned above, the prolongation of wave V latency must be less than 1.5 ms, and the neurosurgeon must recognize this turning point during C-P angle surgery.

[Trigeminal neuralgia associated with primitive trigeminal artery: report of two cases].

Two cases of trigeminal neuralgia associated with the primitive trigeminal artery are reported. From 1981, the authors have treated 131 trigeminal neuralgia patients with microvascular decompression. Among them, we encountered two rare cases of trigeminal neuralgia associated with the primitive trigeminal artery (PTA) and its variant (PTAV). Case 1 is a 74-year-old woman who was admitted to our hospital due to pain of maxilla and mandible. We diagnosed her pain as trigeminal neuralgia. Preoperative angiogram showed the primitive trigeminal artery arising from the cavernous portion of the right internal carotid artery (ICA). She underwent a microvascular decompression operation. We found that her right trigeminal nerve was compressed by the right superior cerebellar artery (SCA) and the right anterior inferior cerebellar artery (AICA). We transferred the offending arteries, and her pain disappeared. Case 2 is a 48-year-old man who was admitted to our hospital due to severe mandibular pain. We diagnosed his pain as trigeminal neuralgia, and he underwent a microvascular decompression operation. His left trigeminal nerve was found compressed by the left SCA and the AICA, and the AICA was arising from the direction of Meckel's cave. His severe pain disappeared completely after operation. Postoperative angiogram of his left ICA showed an aberrant artery arising from the cavernous portion of the ICA, to the region of the left AICA. This aberrant artery is a variant of PTA (PTAV). PTA and PTAV, the so called persistent congenital arteries, are said to accompany aneurysms and other vascular lesions, and affect hemodynamic stress.(ABSTRACT TRUNCATED AT 250 WORDS)

Tic douloureux caused by primitive trigeminal artery or its variant.

Primitive trigeminal artery (PTA) is an extremely rare cause of tic douloureux. None of the reports on PTA variant, which is an anomalous cerebellar artery arising from the internal carotid artery without anastomosis to the basilar artery, has suggested the possibility of this vessel causing tic douloureux. Eight cases of tic douloureux are reported in which a PTA or PTA variant was found during microvascular decompression (MVD). These cases were derived from a series of 1257 patients treated with MVD for tic douloureux. In one patient, the neuralgia was caused by a combination of vessels: a PTA, the superior cerebellar artery, and the anterior inferior cerebellar artery. In the other seven cases, a PTA variant was compressing the root entry zone of the trigeminal nerve. All eight patients gained excellent pain relief after MVD of the root entry zone. The significance of PTA's and PTA variants as the cause of tic douloureux and the effectiveness of MVD in the management of such cases are discussed.

[A case of cerebellar arteriovenous malformation with hemifacial spasm at onset].

A case of cerebellar AVM onset with hemifacial spasm was reported. The patient, a 47 year old woman, had been suffering from lt. hemifacial spasm for 10 years, and she visited our hospital for operation. Preoperative angiography revealed that there was an AVM in the lt. cerebellar hemisphere fed by the lt. SCA and the lt. PICA. In addition, a non-ruptured saccular aneurysm was observed on the feeding SCA. The microvascular decompression was performed and the AVM was removed, since the lt. facial nerve had been compressed by this elongated and redundant PICA. After the operation, lt. hemifacial spasm disappeared. Two months after the operation, the aneurysm disappeared angiographically. These findings indicated that the hemodynamic stress due to the presence of AVM seemed to have resulted in ectasia or redundancy of the PICA and in the development of the aneurysm. Such a case was quite rare and it may be the first time to be reported in literatures.