Microvascular decompression for trigeminal neuralgia due to compression by the vertebral artery: report of 3 cases.

BACKGROUND: Trigeminal neuralgia elicited by the vertebral artery is unusual. According to a large trigeminal neuralgia series, only 4 of 1,404 (0.3%) consecutive patients with typical trigeminal neuralgia presented with vertebral artery compression. In such cases the vertebrobasilar system tends to be atherosclerotic, ectatic, and tortuous, requiring, in addition to an ordinary microvascular decompression method, technical modifications of this procedure. We report on 3 patients with trigeminal neuralgia due to compression by a tortuous vertebral artery. PATIENTS: All 3 patients underwent microvascular decompression via a small lateral suboccipital craniotomy. Operative exposure demonstrated that the root of the trigeminal nerve was compressed directly and stretched by a loop of the vertebral artery. The compression was successfully released by dislocation of the loop using Teflon (polytetrafluoroethene) slings. Immediately after the operation all 3 patients became pain-free. CONCLUSION: Among the surgical procedures used in microvascular decompression surgery, dislocation of the offending vessel with Teflon slings is a useful surgical technique to treat trigeminal neuralgia due to a tortuous vertebral artery.

Yolk sac tumor with a unique uniform hepatoid pattern histology.

BACKGROUND: Yolk sac tumors (YST) exhibit several different histological subtypes and the mechanisms of cellular differentiation and prognosis of each subtype remain unknown. RESULTS: We report two infants with sacrococcygeal YST; one represented a typical histological subtype and the other showed a hepatoid subtype with uniform histology. The isoform of alpha-fetoprotein (AFP) in the patient with the hepatoid pattern was examined by lectin-affinity immunoelectrophoresis and represented as a YST, but not hepatocellular, subtype. The patient with typical YST responded well to VAB-6 combination chemotherapy. However, this regimen was only partially effective to the patient with the pure hepatoid histological subtype, and an etoposide with ifosfamide and cisplatin (VIP) regimen as a salvage chemotherapy combined with complete tumor resection was useful to achieve complete remission (CR). Both of the patients have been in CR for more than four years.

[Vitamin A, B1 and C status of elderly living alone].

A cross-sectional survey was performed to examine the vitamin A, B1 and C status and relating factors among the elderly aged over 65 years and living alone in the western parts of Hachioji, Tokyo. Of 159 subjects, 17 men and 81 women participated in this survey. A questionnaire and interview on the socioeconomic conditions, state of health and life-style and easting habits, and a medical examination were conducted and blood collected and analyzed. Vitamin A, B1 and C status was evaluated on the basis of serum vitamin A concentration, whole blood vitamin B1 concentration and serum vitamin C concentration, respectively. Most of the participants were those who were comparatively active in daily life. Thirty-three percent of the participants were assessed to be in poor vitamin B1 status, while 1% and 4% were assessed to be in poor vitamin A and C status, respectively. Significant correlations were found between whole blood vitamin B1 and serum vitamin A concentrations and between whole blood vitamin B1 and serum vitamin C concentrations. About 10% of the participants had blood vitamin B1 concentrations as below 35 ng/ml and at the same time, significantly lower serum vitamin A and C concentrations than others. Thus, inadequate nutrient intakes or inappropriate diet intakes were suggested as a cause. While good vitamin status was linked with use of vitamin preparations or vitamin supplements, lowered vitamin status was found to be closely associated with such dietary practices or behavior as dietary indifference to food combinations, a higher preference of rice as the staple food and having a reported difficulty in preparing meals.

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.

Effects of high-density lipoproteins on intracellular pH and proliferation of human vascular endothelial cells.

We investigated the effects of high-density lipoprotein (HDL) on the intracellular pH ([pH]i), and on the proliferation of human vascular endothelial cells (HUVEC), as well as on their production of prostacyclin (PGI2). The [pH]i was slightly acidified when extracellular Ca2+ was chelated with EGTA. Pretreatment of HUVEC with amiloride, the Na+/H+ exchange inhibitor, caused the [pH]i to become strongly acidic. The addition of HDL produced a biphasic shift in [pH]i, with a brief initial acidification followed by a rapid alkaline shift. The initial decrease in [pH]i was abolished in the cells pretreated with EGTA, and subsequent alkalinization was inhibited. The alkalinization of [pH]i disappeared in the cells pretreated with amiloride. These results suggest that [pH]i depends mainly on Na+/H+ exchange and partially on the extracellular Ca2+ of the HUVEC either in the resting unstimulated state or during HDL stimulation. In contrast, the addition of LDL produced an acidification of [pH]i, which was increased by LDL in the Ca(2+)-free condition. In the cells pretreated with amiloride, [pH]i was not further acidified by LDL. As a result, HDL promoted the proliferation of cells, an action that was inhibited by pretreatment with EGTA. However LDL inhibited cell proliferation, an action unaffected by EGTA pretreatment. The addition of HDL also enhanced the generation of prostacyclin in endothelial cells, the enhancement of PGI2 generation resulted from an increase in the release of Ca2+ from storage sites, due not only to an increased production of inositol 1,4,5-trisphosphate (IP3), but also to the alkalinization of [pH]i. These effects may be involved in the mechanism of HDL's anti-atherosclerotic action.

[Significance of phrenic nerve block in the anesthetic management of laparoscopic cholecystectomy].

The significance of phrenic nerve block was studied in the anesthetic management of laparoscopic cholecystectomy. Right phrenic nerve block with 1% mepivacaine 10 ml was performed after the patients were epidurally catheterized and anesthetized with isoflurane and nitrous oxide in oxygen. Intraoperative anesthetic requirement and postoperative shoulder pain incidence in patients with this block were compared with those in patients without block. Addition of the phrenic nerve block to general and epidural anesthesia did not reduce the intraoperative dosage of isoflurane, but it significantly prevented occurrence of postoperative right shoulder pain. It is known that phrenic nerve contains sensory element and that laparoscopic procedures of gall bladder elicit noxious stimuli which cannot be blocked by ordinary epidural anesthesia for abdominal surgery. Also, shoulder pain is said to be phrenic nerve-mediated referred pain. Our study suggests that blockade of these stimuli is effective in preventing postoperative event rather than intraoperative.

Plasma levels of soluble fibrin in patients with malignancy-associated disseminated intravascular coagulation.

Disseminated intravascular coagulation (DIC) is one of the most critical complications of malignant diseases. It is conventionally diagnosed by a decrease in platelets and an increase in fibrin/fibrinogen degradation products (FDP). Recently, an immunological assay was developed that can directly quantify the amount of soluble fibrin (SF) formed in the blood. This study examined this assay system in the diagnosis of DIC and found that it is a good indicator of both fibrin formation and of DIC. Plasma levels of SF correlated well with the DIC score, which is determined according to the 'DIC Scoring Guideline' proposed by the DIC Study Group under the Japanese Ministry of Public Welfare in 1988. It also correlated well with the serum levels of FDP. Normal values of plasma SF ranged between 0 and 9.50 micrograms/ml. Interestingly, values of SF in females tended to increase with age, for reasons that are not yet determined.

Successful peritransplant therapy in children with active hepatosplenic candidiasis.

Two pediatric leukemic patients with hepatosplenic candidiasis during multidrug antileukemic chemotherapy successfully underwent bone marrow transplantation (BMT) after aggressive antifungal chemotherapy employing fluconazole and amphotericin B with or without splenectomy. One patient received allogeneic marrow graft and the other received an autologous graft. One patient has been disease-free for more than 21 months after BMT without any recurrence of Candida infection. The other patient showed tentative reactivation of hepatic lesions just after BMT by CT scanning, but these lesions disappeared again by continuous administration of the antifungal agents. The second patient died of leukemia relapse without recurrence of fungal infection. Our cases indicate the possibility of successful BMT once a fungal infection is well controlled by antifungal chemotherapy and surgical resection.

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.

[Evaluation of hypercoagulable state in patients with malignancies by using prothrombin fragment F1 + 2].

In order to elucidate the activation of the coagulation cascade in patients with malignant neoplasms, we measured the levels of plasma prothrombin fragment F1 + 2, which is liberated in the process of thrombin generation. Twenty healthy adults (Group A), 29 patients with malignancies not complicated with DIC (Group B) and 4 patients with DIC (Group C) were evaluated. The values of F1 + 2 in Group C (2.38 +/- 0.55 nmol/l) were significantly higher (p < 0.01) than those in Group A (0.52 +/- 0.19 nmol/l) and B (0.86 +/- 0.68 nmol/l). Many patients in Group B showed higher levels of F1 + 2 compared to normal subjects, however, no significant differences were found between Group A and B. With respect to other coagulation molecular markers such as TAT, D-Dimer and PIC, F1 + 2 levels revealed positive correlation to those levels. Concerning the clinical course of DIC, elevated levels of F1 + 2 normalized much rapidly than those of TAT and D-Dimer by continuous administration of heparin. In conclusion, the measurement of plasma F1 + 2 is important in monitoring the activation of coagulation system in patients with malignancies, especially with respect to early detection and treatment of DIC.

[The effect of epidural analgesia on respiratory muscles].

The effect of epidural analgesia on respiratory functions and muscular power was studied in patients. The subjects had no abnormality of cardiopulmonary system, and were classified into two groups; the adult group whose ages were 21 to 59, and the aged group, 60 to 72. Either 1% or 2% mepivacaine for epidural anesthesia was used to obtain the analgesic level up to Th4 and Th7 in adult group, and Th4 in aged group. The analgesic level was assessed by the pin-prick method. Vital capacity, forced vital capacity, forced expiratory volume 1 second, peak expiratory flow rate, maximal mid-expiratory flow rato, maximal inspiratory pressure and maximal expiratory pressure decreased significantly after epidural anesthesia in all patients whose analgesic levels were up to Th4. In all patients, the change of maximal expiratory pressure was larger than that of maximal inspiratory pressure after epidural analgesia. The patients whose analgesic levels were up to Th7 by 1% mepivacaine in adult group, showed a significant increase of maximal inspiratory pressure. It is concluded that epidural anesthesia diminishes respiratory functions and respiratory muscular power associated with a higher level of analgesia.

Influence of endothelin on human platelet aggregation and prostacyclin generation from human vascular endothelial cells in culture.

The effects of endothelin (ET) on the function of cultured human umbilical vein endothelial cells (HUVEC) and that of human platelets were investigated with reference to endothelium-derived relaxing factor (EDRF) and PGI2. Considering the platelets, ET had no effect on platelet-rich plasma (PRP) aggregation, the generation of thromboxane A2 ([TXA2]) from platelets, and cytosolic free calcium ion concentration ([Ca++]i), cAMP content ([cAMP]i) or cGMP content ([cGMP]i) in platelets. In contrast, the addition of the solution in which HUVEC had been incubated with ET to PRP produced a decrease in PRP aggregation, [TXA2], and [Ca++]i, and an increase not only in [cAMP]i but also in [cGMP]i in platelets. In the HUVEC pretreated with acetylsalicylic acid (aspirin), this increase of [cGMP]i was not affected, but the HUVEC-mediated decrease in PRP aggregation, [TXA2], and [Ca++]i induced by ET were not completely abolished. However, the pretreatment of HUVEC with a combination of aspirin and L-NG-monomethyl arginine (LNMMA) as an inhibitor of EDRF completely abolished the HUVEC-mediated decrease in PRP aggregation, [TXA2] and [Ca++]i induced by ET, and also abolished the enhancement of [cGMP]i and [cAMP]i in platelets. The PGI2 of HUVEC was enhanced by ET with no changes in [Ca++]i, [cAMP]i and [cGMP]i. The ET-induced enhancement was remarkably attenuated by pretreating the HUVEC with aspirin, but not with LNMMA. We conclude that ET attenuates the aggregation of platelets through a decrease in [TXA2] by an increase in [cAMP]i via the increase in PGI2 of HUVEC, and by an increase in [cGMP]i via EDRF.

The immunoregulatory effects of merocyanine 540 on in vitro human T- and B-lymphocyte functions.

Merocyanine 540 (MC 540) is a photoactive dye used to purge bone marrow of tumor cells in autologous bone marrow transplantation. The effects of MC 540 on the lymphoid components in the marrow are unknown. This study evaluates the treatment of lymphocytes by MC 540 (15 micrograms/mL) and light (70 W/m2) on: (1) phytohemagglutinin and Con A-induced proliferation; (2) allogeneic mixed lymphocyte cultures (MLC); (3) the regulation of Ig synthesis by T cells; and (4) the ability of B cells to produce polyclonal Igs as measured by an enzyme-linked immunosorbent assay-plaque assay. The results show that MC 540 and light treatment reduced Con A-stimulated T-cell proliferation greater than 50% after 30 minutes and greater than 80% after 60 minutes of MC 540-sensitized photoirradiation. Ninety minutes of MC 540 and light exposure (designated treatment) inhibited MLC greater than 90%. In polyclonal Ig synthesis, T-cell helper activity could be abrogated by 90 minutes of treatment in cocultures containing untreated B cells. Purified B cells treated for 90 minutes cocultured with normal T cells did not produce Ig. Treatment of B cells completely inhibited Epstein-Barr virus-stimulated Ig synthesis. These data show that T- and B-cell immunity is suppressed by the MC 540-sensitized photoirradiation. Treatment of bone marrow with MC 540 and light may have profound effects on immune reconstitution in autologous marrow graft recipients. More provocative is the fact that the same immunomodulatory effects may be applicable to partially mismatched marrow transplant situations as a means of reducing graft-versus-host reactions.

Effect of cyclic GMP and sulfhydryl on prostacyclin production by human vascular endothelial cells.

The relationship between sulfhydryls and cGMP has been observed in several biological processes. Captopril is a sulfhydryl-containing angiotensin converting enzyme (ACE) inhibitor, that decreases PGI2 production in cultured human vascular endothelial cells. Enalapril does not appear to have this property. The role of cyclic GMP (cGMP) and sulfhydryls in the regulatory mechanisms in captopril-induced PGI2 production and Ca++ kinetics was investigated. Bradykinin and Ca ionophore A23187 enhanced PGI2 production, and increased the cytosolic free Ca++ concentration ([Ca++]i). It was observed that 8-bromo cGMP increased intracellular cGMP concentration ([Ca++]i), and decreased PGI2 production without changing [Ca++]i. Sulfhydryl containing compounds such as captopril, N-acetylcysteine and glutathione decreased PGI2 production via increased [cGMP]i. Enalapril, an ACE inhibitor without sulfhydryls, has no effect on PGI2 production, [Ca++]i and [cGMP]i. These results suggested that the presence of sulfhydryl groups is an important factor in the ability of vasoactive substances to induce PGI2 production.

Failure of T cell receptor-anti-CD3 monoclonal antibody interaction in T cells from marrow recipients to induce increases in intracellular ionized calcium.

There are multiple immune defects in T cells from recipients after bone marrow transplantation (BMT). This study examines recipient T cells for increases in intracellular ionized calcium concentration [( Ca2+]i) after binding the T cell receptor-CD3 complex with anti-CD3 MAb. PBL from 10 of 23 short-term recipients (less than 1 yr after BMT) responded poorly (less than 35% of control) to anti-CD3 stimulation and PBL from 9 of 23 had blunted calcium flux responses (35-70% of control). Purified CD2+, CD56- cells from seven additional short-term recipients including three autologous marrow recipients were closely examined, and a sizable proportion of CD3+ cells from six of seven recipients did not increase [Ca2+]i after anti-CD3 stimulation. The decreased magnitude of the responses was due to decreased numbers of responding cells and not to a decrease in mean CD3 fluorescent intensity or in calcium flux responses on a single cell basis. Five of seven long-term recipients (greater than 1 yr after BMT) had PBL that responded normally and two of seven had PBL with blunted calcium flux responses. The data show that the signal transduction response mediated by the CD3-antigen receptor as measured by calcium flux is defective early after autologus or allogeneic BMT.

Immune status in two brothers with Omenn's syndrome: no discernible chimerism on FACS analysis using a monoclonal antibody specific for a maternally restricted HLA antigen.

Sequential immunologic examinations, including lymph node biopsies, in two brothers with clinical characteristics of Omenn's syndrome are presented in this study. Although the number of circulating T cells with mature phenotype (OKT3+, TCR1+) was within normal range, the lymphocyte proliferative response to mitogens was poor. Examinations of the lymph nodes revealed marked lymphoid depletion associated with eosinophilic infiltration and reticular cell proliferation. Over the clinical course of 5 months, circulating T cells also mostly disappeared. Thymic hypoplasia was noted at autopsy. Although intrauterine graft-versus host disease (GVHD) has been hypothesized as being the pathogenetic mechanism in this syndrome, maternal lymphocytes circulating in these patients were not identified either by karyotype and HLA typing or by highly sensitive FACS analysis and immunohistochemical studies using a monoclonal antibody, HLA-A9, specific for a maternally restricted HLA antigen, Aw24. In conclusion, the familial occurrence and the absence of maternal chimerism might be the essential features of Omenn's syndrome which should be differentiated from fetal GVHD.

Different Ia antigen characterization between granulocyte progenitor cells (CFC-G) and monocyte-macrophage progenitor cells (CFC-M).

Ia-like antigen-positive (Ia+) and -negative (Ia-) cell populations were separated from human cord blood cells and bone marrow mononuclear cells by a rosette technique with a combined use of staphylococcal protein-A-coated bovine red blood cells and the monoclonal OKIa 1 antibody, or by using a cell-sorting technique. Colony-forming units-granulocytes-monocytes-macrophages (GFU-GM) were assayed in a semisolid agar culture, and colony-forming cells-granulocytes (CFC-G) were differentiated from colony-forming cells-monocytes-macrophages (CFC-M) by double staining for esterase activity. The majority of CFC-G in cord blood was grown in the Ia+ fraction; Ia+ CFC-G/Ia- CFC-G = 1.62 +/- 0.34 (mean +/- SD), which was similar to the ratio in bone marrow (Ia+/Ia- = 1.80 +/- 0.37). In contrast, the majority of CFC-M in cord blood was grown in the Ia- fraction; Ia+/Ia- for CFC-M = 0.50 +/- 0.09. The predominance of CFC-G in the Ia+ fraction in contrast to predominance of CFC-M in the Ia- fraction was confirmed by using a cell-sorting technique. T-lymphocyte depletion and the culture supernatants of Ia+ and Ia- cells did not affect differentiation of CFC-G and CFC-M. These data suggest that there are potent differences in the expression of Ia-like antigens between CFC-G and CFC-M, indicating that the Ia+ progenitor cell population generates predominantly CFC-G, whereas the Ia- population generates mainly CFC-M during the maturation process in granulopoiesis.