Detection of Epstein-Barr virus DNA and expression of CD30 antigen in primary anaplastic diffuse large B-cell lymphoma of the brain.

We describe a case of primary anaplastic diffuse large-cell lymphoma arising in the central nervous system (CNS). Primary CD30-positive anaplastic diffuse large B-cell lymphoma of the brain is very rarely reported. Given that this tumor is immunohistochemically heterogeneous, polymerase chain reaction (PCR) and Epstein-Barr virus (EBV) analysis of tumor DNA are essential techniques for early and accurate histological diagnosis in these CD30-positive cerebral lymphoma cases. We report an early CD30- and EBV-positive anaplastic diffuse large B-cell lymphoma in the CNS that was diagnosed not only from the immunohistochemical study and MRI findings, but also from the genotype confirmations. This tumor was documented to have EBV episomes of monoclonal origin by PCR analysis of immunoglobulin gene rearrangement.

[Metabolic acidosis and ketone body in severely head-injured patients].

Increase of ketone body concentration in plasma is induced by various factors such as onset of diabetes. Secretion of excessive stress hormone including catecholamine is responsible for stimulation of lipolysis which increases plasma ketone body concentration. Catecholamine levels reflect the severity of the neurologic insult, so this is a basis for the use of catecholamine measurements as a physiological marker of patient outcome. Twenty-seven patients with severe head injury and twenty-five healthy volunteers were enrolled in this study, but patients with diabetes or liver dysfunction were excluded. The patients with severe head injury consisted of 19 with focal injury and 8 with diffuse injury. The outcome was as follows; 14 patients died and 13 patients survived. We collected arterial blood samples as promptly as possible after onset of severe head injury and measured the following: 1, base excess; 2, beta-hydroxybutyrate; 3, acetoacetate; 4, lactate; 5, epinephrine; 6, norepinephrine. The ketone body (beta-hydroxybutyrate + acetoacetate) concentration in plasma was significantly elevated in patients with severe head injury. The increment of beta-hydroxybutyrate levels was greater than that of acetoacetate levels, resulting decreased arterial ketone body ratio (AKBR; acetoacetate/beta-hydroxybutyrate). We demonstrated that plasma ketone body concentrations were elevated and the AKBR decreased in severe head-injured patients. Elevation of catecholamine has been reported as a stress reaction in severe head injury. Catecholamine is most potent in stimulating lipolysis, and ketogenesis. Therefore, the ketonemia observed in severe head injury is most likely to be induced by elevation of catecholamine levels. The degree of ketonemia may be an index of the severity of severe head injury.

Intracranial malignant meningioma with abdominal metastases associated with hypoglycemic shock: a case report.

A thirty-year-old male with an intracranial malignant meningioma, first diagnosed 9 years ago, with three recurrences was admitted with a hypoglycemic shock. The blood glucose level was 17 mg/dl, requiring treatment with high doses of intravenous and oral dextrose for improvement. A large metastatic tumor in the liver was noted. All hormones and peptides influencing blood glucose levels were in their normal levels. Chemo-embolization and injection of anti-cancer drugs was employed in the management of the metastatic tumor. Positron emission tomography was performed to measure the glucose metabolism of the abdominal tumor and it indicated that glucose consumption within the tumor was much elevated than the surrounding abdominal organs. Hypoglycemia secondary to primary hepatoma or islet-cell cancer has been frequently described, but a complication of metastatic meningioma is an exceedingly rare event. Elevated glucose consumption within the tumor might be addressed as one of the reasons for hypoglycemia, not due to the elevated serum levels of insulin or IGF, but due to the closely related blood glucose level.

Ruptured aneurysm of the orbitofrontal artery associated with dural arteriovenous malformation in the anterior cranial fossa--case report.

A 27-year-old male presented with a rare association of a ruptured orbitofrontal artery aneurysm and a dural arteriovenous malformation (DAVM) fed by both ethmoidal arteries, manifestation as severe headache, nausea, and vomiting. Computed tomography revealed a hematoma within the right frontal lobe and diffuse subarachnoid hemorrhage. The aneurysm was clipped successfully and the hematoma was evacuated. After an uneventful postoperative course, the patient was referred for gamma knife radiosurgery to treat the DAVM. In this case, the DAVM was asymptomatic and pathogenetically unrelated to the aneurysm, which demanded urgent treatment.

Treatment of posterior skull base tumors.

Surgery for posterior skull base tumors may be associated with high morbidity and mortality because of the complex anatomy, irregular bony topography, and vital neurovascular structures in this region. We experienced three benign posterior skull base tumors. These were petroclival and foramen magnum meningiomas and a jugular formen neurinoma. Three dimensional computed tomography (3 D-CT) in addition to the conventional CT, magnetic resonance imaging (MRI), and cerebral angiography were performed preoperatively. Preoperative embolizations for the tumors were also done, and intraoperative neurophysiological monitorings were performed. The tumors could be subtotally removed with no damage to the brainstem, cranial nerves, and vessels. No newly developed postoperative neurological symptoms were observed. As to the remaining tumors, gamma knife (gamma-knife) therapy was planned. 3 D-CT was very useful in the preoperative evaluation of the surgical approach, and the intraoperative neurophysiological monitoring was considered to be necessary to prevent permanent damage. gamma-knife after direct approach was recommended for the benign posterior skull base tumors.

Malignant fibrous histiocytoma in the parietal bone.

Malignant fibrous histiocytomas (MFHs) are mesenchymal tumors, usually arising in soft tissue of the extremities and are remarkably resistant to radiation and chemotherapy. A 45-year-old female presented with a rare case of MFH originating in the cranial bone manifesting as a lump in the left parietal region with no neurological abnormality. Neuroimaging revealed the presence of an osteolytic tumor in the left parietal bone invading into muscle and subdural region, penetrating through the dura. Selective external carotid angiography disclosed a marked tumor stain. Examination of the whole body excluded neoplastic disease elsewhere. The patient was treated by surgical excision, radiation, and two courses of multi-drug chemotherapy using cyclophosphamide, doxorubicin, vincristine, and prednisolone. Since there is no established treatment against this malignancy, a longer follow-up is necessary to determine whether cure has been achieved.

[Postoperative three-dimensional CT angiography (3D-CTA) in evaluation of proximal clipping for ruptured vertebral aneurysms].

At present, intra-arterial angiography remains the gold standard for most cerebrovascular problems. Recently, three-dimensional computed tomographic angiography (3D-CTA) has been reported as a screening method for the diagnosis of cerebrovascular disease. This imaging modality uses the information obtained on a contrast-enhanced CT scan to generate three-dimensional images of the cerebrovascular system. We performed 3D-CTA in the preoperative and postoperative evaluation of patients undergoing proximal clipping of ruptured vertebral artery aneurysms in addition to conventional cerebral angiography. In this study, the value of 3D-CTA after proximal clipping of ruptured vertebral artery aneurysm was evaluated retrospectively. Six patients were examined with a spinal CT (HITACHI CT-W 3000) after intravenous bolus injection of 100 ml contrast material (Iohexhol 300 mgI/ml) at the rate of 2 ml/s with a 25 second pre-scanning delay. The images of 3D-CTA were reconstructed using a new 3D-volume-render (Voxel Transmission) technique. The ages of the six patients ranged from 33 to 61 years and five cases were males and one case was female. Only one patient had a saccular aneurysm and the other five had fusiform aneurysms. Two patients underwent emergency operations within 4 days, and the other four had delayed operations. The outcome was good recovery in five cases and severe disability in one case. Postoperative conventional cerebral angiography demonstrated no delineation of the aneurysms in five cases. These results correspond well to postoperative 3D-CTA. Postoperative conventional cerebral angiography could not be performed in only one patient, but the aneurysm was visualized on the third postoperative 3D-CTA. Proximal clipping is still one of the therapeutic options for ruptured vertebral aneurysms, but some reports emphasized the possibility of rebleeding after proximal clipping of vertebral artery aneurysms. The rebleeding occurred within 1 week after proximal clipping in 6 of 9 cases (66.7%), and the prognoses were extremely poor. Therefore, in patients selected for proximal clipping, it is necessary to undertake postoperative evaluation of the aneurysm within one week after proximal clipping. 3D-CTA is minimally invasive and can be easily performed repeatedly, even if the patients are in a poor condition. In conclusion, 3D-CTA is very useful especially for evaluation of ruptured vertebral artery aneurysms following proximal clipping.

[Correlation of serial MRI and histological findings following intra-tumor local chemotherapy for malignant brain tumor].

Serial magnetic resonance imaging (MRI) studies on patients with malignant brain tumor after postoperative adjuvant therapy have been rarely reported. Leukoencephalopathy after such treatment is a well-known serious adverse effect, which we studied by serial MRI after postoperative adjuvant therapy in 15 patients with malignant brain tumors (anaplastic glioma 6, astrocytoma Grade III 5, astrocytoma Grade II 2, and metastatic brain tumor 2) (Table 1). All patients were examined by MRI, more than twice postoperatively. Adjuvant therapy was as follows: adriamycin (ADM) (0.5 mg) was injected through Ommaya reservoir into the tumor bed at the craniotomy. The usual total dose of ADM was 5.0 mg. In three of 15 patients, local methotrexate chemotherapy was added. Fourteen patients received a course of local irradiation 58 Gy on average combined with local ADM chemotherapy. Histological findings of three autopsy cases and ten reoperated ones were correlated with the serial MRI. Consecutive MRI were examined one and three months after adjuvant therapy. The results were as follows: One month after adjuvant therapy, thin and high signal intensity areas could be seen in the marginal zone of the tumor cavity on the gadolinium-enhanced T1-weighted MRI. High signal intensity areas could also be seen in the operative cavity on the T1-weighted MRI, which were suspected to be residual hematomas. In one patient, a high, diffuse and widespread signal area could be seen on T2-weighted MRI, suggesting leukoencephalopathy. Three months after adjuvant therapy, a high thick signal intensity area could be seen in the marginal zone of the tumor cavity and along the route of the Ommaya tube on the gadolinium-enhanced T1-weighted MRI, but there was no mass effect in these space taking lesions. In five cases, a low signal intensity area could be seen in the porencephalic cystic lesion, in one of which septum formation of cystic cavity was detected on the gadolinium-enhanced T1-weighted MRI. Morphologically, there was massive coagulation necrosis in the tumor cavity, but in the vicinity of the cystic wall abundant fibrous connective tissue was found to correspond with the high and thick signal intensity area on the above-mentioned gadolinium-enhanced T1-weighted MRI.(ABSTRACT TRUNCATED AT 400 WORDS)

[Neuropathological study of battered child syndrome: eight autopsy cases].

The term "battered-child syndrome" was coined by Kempe in 1962. The morphology of brain lesions in abused children is rarely reported in Japan. This clinicopathological entity in the central nervous system is characterized by retinal hemorrhages, subdural and subarachnoid hemorrhage. However, reports on microscopic findings of intracerebral lesion are fewer than those on macroscopic findings of scalp, skull and intracranial cavity. This study was performed on 8 cases of battered children who were autopsied. They consisted of six female and two male infants. The age ranged from one week to four years old. The causes of the injuries were shaking in four cases, throwing in three cases, dropping in two cases and strangling in one case, mostly in combination. CT scans were examined for three cases. CT scan revealed acute cerebral swelling and acute subdural hematoma with interhemispheric blood clot in three cases and multiple low density area in one case. Evacuation of the subdural hematoma and external decompression was performed in one case. The survival period from injury to death was one day in four cases, and 2, 3, 9 and 41 days in the others. In the gross anatomical findings there are many excoriations and bruises of the face and scalp in five cases, widespread subcutaneous hematoma in all cases and skull fracture in only two cases. The brain weight was exceedingly heavier than normal brain weight by age in five cases. In the macroscopic findings, there were marked cerebral swelling and cerebral herniation in all cases, traumatic subarachnoid hemorrhage in six cases, and thin widespread acute subdural hematoma with interhemispheric clot in four cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cyst formation following local chemotherapy of malignant brain tumor: a clinicopathological study of two cases].

This paper reports clinicopathological findings concerning an enlarged bulky cyst and the tumor cavity following local administration of an anticancer agent combined with radiotherapy in two patients suffering from malignant glioma. Case 1: This 69 year-old man who had been diagnosed as having glioblastoma in the right parietal lobe had received local chemotherapy after the first operation. Simultaneously radiotherapy of 69 Gy in total dose was performed. At the second operation for the tumor, cyst formation was clinically confirmed and necrotomy as well as evacuation of the large cyst was performed after adjuvant therapy. The patient died at a time ten months after the first surgical operation. Case 2: This is the case of a 48 year-old man who was diagnosed as having gemistocytic astrocytoma in the left frontal lobe. The first surgical operation was performed and was followed by local chemotherapy as well as radiotherapy (total dose of 90 Gy in two sessions). The second surgical operation of the recurrent tumor, with necrotomy and evacuation of the large cyst were performed after adjuvant therapy. The patient expired at a time sixty-five months after the first surgical operation. Relevant to the chemotherapy, adriamycin (ADM) (0.5mg) and methotrexate (MTX) (1mg) were administered through the Ommaya's reservoir into the tumor bed at craniotomy. The usual doses of ADM and MTX amounted to 5.0mg respectively. Through conventional CT and MRI, formation of a cyst including abundant membranous debris or septi was identified in both cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical study of mannitol and glycerol on raised intracranial pressure and on their rebound phenomenon.

UNLABELLED: We have studied the effects of mannitol and glycerol on raised ICP as monitored by epidural pressure recordings in 65 patients. Four methods of infusion were assessed. In group A, 0.5 g/kg mannitol was infused within 15, 30, or 60 min. In group B, 1.0 g/kg mannitol was infused within 30, 60, or 90 min. In group C, 0.5 g/kg glycerol in 5% fructose was infused within 30, 60, or 90 min. In group D, 1.0 g/kg glycerol was infused within 60, 120, or 180 min. RESULTS: (a) In group A, there was no difference in the reduction of ICP among the three infusion rates. In group B, the degree of ICP reduction increased with shorter times of infusion. In the groups receiving glycerol, the reduction of ICP was inversely related with the rate of infusion. (b) In every group, it appeared that the slower the infusion rate of the same dosage became, the longer the reduction of ICP lasted. (c) A rebound phenomenon occurred in 12% of the mannitol groups and 34% of the glycerol groups. The dose and the rate of mannitol infusion did not influence the occurrence of the rebound phenomenon. In the glycerol groups, the infusion method did influence the occurrence of rebound phenomenon. Our present study demonstrated that there were differences between mannitol and glycerol infusion in their effectiveness and in the occurrence of rebound phenomenon.

[Histopathological study of a recurrent malignant glioma after an intratumor local injection of adriamycin].

This paper presents interesting morphological findings, which have never been previously reported, on tumor tissues after a local injection of an anticancer agent into three patients with malignant glioma. Following a craniotomy, 0.5 mg of Adriamycin (ADM) was injected through an Ommaya reservoir into the tumor bed. Light microscopy of the recurrent tumor and surrounding necrotic tissue revealed massive coagulation necrosis of the tumor tissues and fibrinoid necrosis of vascular channels, centering at the tip of the Ommaya tube. In the surrounding area of the massive coagulation necrosis, considerable reactive collagenous tissue, infiltrating lymphocytes and foreign body giant cell were found as well as so-called "organized" necrotic tissue. Electron microscopic findings of the same specimens revealed deposits of lipofuscin, lipid droplets, lysosome, abundant myelin figures and fibrous strands. It can therefore be assumed that this or similar anticancer agents, when may be directly incorporated into the residual tumor cells, are apparently reduced by coagulation necrosis and reactive collagenous tissue.