Comparison between in vitro qualities of platelets washed with commercially available additive solutions and those washed with M-sol.

BACKGROUND AND OBJECTIVES: We previously developed a novel additive solution (M-sol) with a high ability to preserve the in vitro qualities of platelets (PLTs) in washed PLTs Here, we compared the ability of M-sol with that of commercially available additive solutions (ASs) to preserve the in vitro qualities (pH, mean PLT volume, %disc, P-selectin, %hypotonic shock response and aggregation) of PLTs at a low plasma concentration. MATERIALS AND METHODS: The platelet concentrate was divided into two equal aliquots (control group and test group). After centrifugation of both groups and removal of as much supernatant as possible, the pellet of the control group was resuspended in M-sol and those of the test group were resuspended in other ASs, and subsequently stored in polyolefin bags with agitating at 20-24 degrees C. RESULTS: Compared with those stored in M-sol, the qualities of PLTs stored in PAS-B (alternative name; PAS-II or T-sol), PAS- C (alternative name; PAS-III or Intersol) or Plasma Lyte were degraded as early as 24 h after washing. The qualities of PLTs stored in PAS-D (alternative name; Composol PS) or PAS-E (alternative name; PAS-IIIM or SSP+) were comparable to that of those stored in M-sol 24 h after washing; however, the qualities had deteriorated 72 h after washing. CONCLUSIONS: At a low plasma concentration (5% or less), the M-sol showed a higher ability to preserve PLTs than the five ASs studied here. Although PAS-D and PAS-E are available as an AS for short-term storage of washed PLTs, M-sol is thought to be preferable for longer storage.

Ultra-early MRI showing no abnormality in a fall victim presenting with tetraparesis.

STUDY DESIGN: Case report. SETTING: Department of Neurosurgery, Sapporo Azabu Neurosurgical Hospital and Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan. CASE REPORT: A patient presented to us with complete C4 tetraplegia after a 3-m fall. MRI performed 120 min after his fall showed spinal canal stenosis due to disk protrusion at the C3/4 level without spinal cord signal changes on T1- and T2-weighted images. He underwent laminoplasty between C2 and C6. Intraoperative ultrasound, performed 6 h after his fall, disclosed a hyperechoic lesion at the C3/4 level of the cervical cord; postoperative T2-weighted MRI, obtained at 8 h after his fall, showed high intensity at the same level. CONCLUSION: In patients with cerebral infarction, approximately 6 h between the insult and the acquisition of T2-weighted MRI are required to detect signal changes. We postulate that the time course on MRI scans obtained immediately after spinal cord injury is similar in patients with spinal cord injury and cerebral infarction and suggest that the absence of spinal cord abnormalities in the ultra-early post-injury stage is not always predictive of a good prognosis.

Anterior decompression of the atlantoaxial vertebral artery to treat bow hunter's stroke: technical case report.

OBJECTIVE AND IMPORTANCE: Bow hunter's stroke is a symptomatic vertebrobasilar insufficiency caused by stenosis or occlusion of the vertebral artery at the C1C2 level with head rotation. No case of anterior decompression of the vertebral artery for surgical treatment of bow hunter's stroke has been reported. CLINICAL PRESENTATION: A 47-year-old male patient presented with repeated episodes of unconsciousness caused by turning his head approximately 40 degrees to the right; he recovered consciousness within approximately 10 seconds after his head was returned to the neutral position. Angiography revealed an occluded right vertebral artery and temporary occlusion of the left vertebral artery, at the level of the C2 transverse foramen, when the patient's head was turned approximately 40 degrees to the right. INTERVENTION: Anterior decompression of the left vertebral artery at the transverse foramen of the axis was performed. Postoperative angiography demonstrated sufficient flow in the left vertebral artery even when the neck was rotated. CONCLUSION: The patient was discharged without neurological deficits. We demonstrate that simple surgical untethering of the vertebral artery at the transverse foramen of the axis is an effective method of treatment that avoids the limitation of head rotation. The advantage of this procedure is that it does not result in postoperative restriction of the patient's neck movements. The anterior approach, with decompression of the transverse foramen of the axis, in the present case provided adequate exposure of the vertebral artery and resulted in a satisfactory outcome.

Evolution of left ventricular involvement in arrhythmogenic right ventricular cardiomyopathy.

Left ventricular (LV) involvement in arrhythmogenic right ventricular cardiomyopathy (ARVC) is fairly well known, but the evolution of LV involvement during long-term follow-up has not been well documented. We describe such evolution in a patient followed for 9 years. Evolution was confirmed by a progressive perfusion defect of the LV wall in myocardial scintigrams and by the development of LV asynergy with ventricular aneurysm formation in left ventriculograms. As the right ventricle progressively enlarged, we concluded that ARVC is a diffuse and progressive myocardial disease that affects both ventricles.

[Efficacy of cibenzoline for chest oppression and ventricular arrhythmia during effort and alcohol consumption in a patient with hypertrophic obstructive cardiomyopathy: a case report].

A 67-year-old man presented with chest oppression and palpitation during effort and alcohol consumption. Echocardiography demonstrated asymmetric septal hypertrophy and systolic anterior motion of the anterior mitral leaflet with a pressure gradient of 80 mmHg across the left ventricular outflow tract (LVOT), leading to the diagnosis of hypertrophic obstructive cardiomyopathy. During the treadmill exercise test, blood pressure decreased with electrocardiographic ST-segment depression and subsequent frequent premature ventricular contractions. Holter-electrocardiographic monitoring also showed ST-segment depression with premature ventricular contractions during effort and alcohol consumption. Coronary angiography showed no abnormalities and cardiac catheterization at baseline showed a systolic pressure gradient of only 2 mmHg across the LVOT. However, the gradient increased to 33 mmHg after premature ventricular contraction, 27 mmHg at Valsalva maneuver and 75 mmHg with dobutamine infusion (5 micrograms/kg/min) and disappeared with 70 mg of intravenous cibenzoline. Medication with cibenzoline (300 mg/day) for one month reduced the LVOT gradient at rest to 53 mmHg and strikingly improved symptoms and exercise tolerance and also suppressed premature ventricular contractions during exercise and alcohol consumption. We conclude that cibenzoline was effective for reduction of LVOT gradient both at rest and during exercise and alcohol consumption.

Acute cervical cord injury without fracture or dislocation of the spinal column.

OBJECT: It is known that the spinal cord can sustain traumatic injury without associated injury of the spinal column in some conditions, such as a flexible spinal column or preexisting narrowed spinal canal. The purpose of this study was to characterize the clinical features and to understand the mechanisms in cases of acute cervical cord injury in which fracture or dislocation of the cervical spine has not occurred. METHODS: Eighty-nine patients who sustained an acute cervical cord injury were treated in our hospitals between 1990 and 1998. In 42 patients (47%) no bone injuries of the cervical spine were demonstrated, and this group was retrospectively analyzed. There were 35 men and seven women, aged 19 to 81 years (mean 58.9 years). The initial neurological examination indicated complete injury in five patients, whereas incomplete injury was demonstrated in 37. In the majority of the patients (90%) the authors found degenerative changes of the cervical spine such as spondylosis (22 cases) or ossification of the posterior longitudinal ligament (16 cases). The mean sagittal diameter of the cervical spinal canal, as measured on computerized tomography scans, was significantly narrower than that obtained in the control patients. Magnetic resonance (MR) imaging revealed spinal cord compression in 93% and paravertebral soft-tissue injuries in 58% of the patients. CONCLUSIONS: Degenerative changes of the cervical spine and developmental narrowing of the spinal canal are important preexisting factors. In the acute stage MR imaging is useful to understand the level and mechanisms of spinal cord injury. The fact that a significant number of the patients were found to have spinal cord compression despite the absence of bone injuries of the spinal column indicates that future investigations into surgical treatment of this type of injury are necessary.

[Invasive examination of cardiovascular disease].

Invasive cardiovascular examination by coronary angioscopy and by using a Doppler guide wire, a pressure guide wire and intravascular ultrasound has extensively developed. A Doppler guide wire is used for measurement of flow velocity and evaluation of coronary blood flow. Previous studies demonstrated by assessing maximum coronary vasodilatory capacity that endothelium-dependent or independent vasodilation was impaired in hypertension and hypercholesterolemia or in syndrome X. Elevation of coronary vascular resistance during coronary microvascular spasm has been verified by using a Doppler wire. A pressure guide wire provides coronary transstenotic pressure and is available in calculating myocardial fractional flow reserve(FFRmyo). FFRmyo is an important parameter to assess the coronary functional stenosis that is culprit for myocardial ischemia. It is calculated from the ratio of the mean transstenotic pressure to the mean pressure proximal to the stenosis during maximum coronary hyperemia. The value of FFRmyo considered as necessary for coronary intervention is below 0.75. Intravascular ultrasound(IVUS) is applied as both a diagnostic tool and for intervention purpose. It enabled tissue characterization of the vascular wall as well as measurements of vascular diameter, vascular lumen area and plaque area. It also aided in optimal devise selection, decision of interventional endpoint and assessment of restenosis. IVUS promoted deployment of high-pressure stents to obtain a large post-procedural lumen area as well as abolition of anticoagulation in case of optimal stent deployment. Coronary angioscopy has been developed to investigate the pathogenesis of acute coronary syndrome, where disrupted yellow plaque and overlying thrombus play important roles. Angioscopy has also evidenced regression of intimal hyperplasia after coronary stenting.

Factors in neurological deterioration and role of surgical treatment in lumbosacral spinal lipoma.

The purpose of this study was to determine factors that might be involved in neurological deterioration and the role of surgical treatment in patients with lumbosacral spinal lipoma. Pre- and postoperative courses of 34 patients were retrospectively analyzed. The age at surgery ranged from 1 month to 47 years. The records of preoperative neurological status indicated that older patients had more severe deficits, while all 8 asymptomatic patients were under 5 years of age. Motor deficits were noted in 9 patients, in 7 of whom the lipoma extended cranially beyond the L5 level. Transitional-type lipomas were accompanied by more severe deficits (asymptomatic 1, symptomatic 17) than other types (asymptomatic 7, symptomatic 9). Postoperative follow-up periods ranged from 5 months to 13 years. During these periods, 7 of the 8 asymptomatic patients remained neurologically intact. Nine of the 26 symptomatic patients improved. Age, extension of the lipoma in the spinal canal and type of lipoma will influence the preoperative neurological status of the patients. Early untethering surgery is recommended in patients with large lipomas extending beyond the L5 level.

Chronological changes in MRI findings of spinal dural arteriovenous fistula.

BACKGROUND: Intramedullary high-intensity changes on T2-weighted magnetic resonance images (MRI) occur in patients with spinal dural arteriovenous fistulas (AVF). Reduction of the high-intensity area after treatment has been noted; however, there are still questions about whether the change is related to preoperative clinical grade, postoperative improvement, or efficacy of treatment. This study tried to clarify the relationship between chronological changes in the high intensity area with the treatment and clinical course. METHODS: Chronological changes in an intramedullary high-intensity area after surgery were retrospectively analyzed in recent 13 patients with spinal dural AVFs who were treated and followed by MRI. RESULTS: Preoperative intramedullary high-intensity areas were observed on T2-weighted images in all cases. The extent of the high-intensity area correlated with preoperative neurological deficits. The intramedullary high-intensity area was reduced or diminished after successful interruption of AVFs. The high-intensity area started to decrease within 1 to 4 months after treatment in all patients, and disappeared at 2 weeks to 23 months in seven patients. The reduction may suggest interruption of the fistula and improvement of venous circulation, but was not always correlated to clinical improvement. The intramedullary high-intensity areas rapidly disappeared in two patients, but did not clearly correspond to the clinical improvement. CONCLUSIONS: The time course of postoperative MRI changes is helpful for evaluating the efficacy of treatment after surgery for spinal dural AVFs.

Magnetic resonance angiography for detection of occlusive neck and proximal vascular diseases.

We reviewed magnetic resonance (MR) aortographies of the thoraco-cervical region of 422 patients. Two hundred sixty patients had ischemic cerebrovascular disease, 86 vertigo or dizziness, 22 syncope, 4 ischemic disease of the retina, 3 cervical bruit, and 47 had other intracranial diseases. MR aortography was performed on a 1.5 Tesla MRI using a special head-and-neck coil. Images were obtained using an overlapping multi-slab and three-dimensional time-of-flight technique. Of the 422 patients, 59 underwent conventional angiography, and the findings from their conventional arteriogram were compared with those of MR aortography. As a result, steno-occlusive lesions were found in the carotid system in 21.1% of the patients, in the vertebral system in 18.5%, and in the subclavian and innominate arteries in 2.1%. The diagnoses made based on the MR aortography were in accord with the diagnoses made with conventional arteriography in 49 patients (83.1%). In 8 patients (13.6%), however, the diagnosis based on the MR aortography was found to be overestimated compared with the definitive diagnosis with conventional angiography. In only 2 patients (3.3%), the MR aortography diagnosis was insufficient. Especially, subclavian steal was not diagnosed with the MR aortography, whereas the findings from the MR aortography helped to lead to the diagnosis of this abnormality. In conclusion, we found that MR aortography is a useful tool as a screening test for patients with occlusive extracranial cerebrovascular disease.

[Cervical epidural hematoma caused by cervical twisting after epidural anesthesia: a case report].

A case of cervical epidural hematoma caused by cervical twisting after epidural anesthesia was reported. A 41-year-old man who had had anterior fusion of C5 - 7 using a plate due to cervical spondylosis fifteen months before admission, had undergone epidural anesthesia through the C7/T1 interspace without difficulty for shoulder pain in a pain clinic. Two hours after injection, he complained of severe pain in his neck and both shoulders just after cervical twisting as was his custom. Within minutes he noted paresis of his left extremities. Neurological examination on admission revealed left side dominant tetraparesis and loss of pain and temperature sensations below the level of T4 on his right side. Laboratory data analysis and coagulation tests were normal. CT scans and MRI demonstrated an epidural hematoma with a small amount of air extending from C3 to the upper margin of C7. Four hours after the onset, a laminoplasty was performed from C3 to C7 with total removal of the hematoma. No bleeding site or any vascular abnormality was found to account for the hematoma formation. He was discharged with good recovery after operation. Most of the reported epidural hematomas associated with epidural anesthesia were related to coagulopathy, anticoagulant therapy or difficult puncture. On review of the literature, this is the first case of spinal epidural hematoma cause by cervical twisting after spinal anesthesia and which was without impaired coagulation or difficult spinal puncture. Cervical epidural hematoma should be considered as a possible complication in patients with pain or neurological deficits after some cervical manipulations.

Ocular tilt reaction with vertical eye movement palsy caused by localized unilateral midbrain lesion.

A 60-year-old man developed diplopia and experienced difficulty moving his eyes. Vertical movement of each eye, including vestibulo-ocular reflex and smooth pursuit, was extremely limited. Horizontal eye movements were normal. His head position was tilted toward his left. There was 10 prism diopters of exotropia and 10 prism diopters of right hypertropia. Fundus photographs revealed a clockwise torsion of both eyes. These signs indicate leftward ocular tilt reaction. Magnetic resonance imaging showed a small area of an increased signal intensity localized in the midbrain dorsomedial to the red nucleus on the right side. Based on recent experimental evidence, it may be assumed that the unilateral lesion involving the right interstitial nucleus of Cajal most probably caused leftward ocular tilt reaction in our patient.

Phosphorus-31 magnetic resonance spectroscopy studies of pig spinal cord injury. Myelin changes, intracellular pH, and bioenergetics.

RATIONALE AND OBJECTIVES: Phosphorus-31 (31P) nuclear magnetic resonance (NMR) spectroscopy was used to monitor changes in phosphocreatine (PCr), adenosine triphosphate (ATP), inorganic phosphate (Pi), intracellular pH (pHi), and free magnesium in the in vivo pig spinal cord after injury. METHODS: Phosphorus-31 NMR spectra were acquired from healthy (n = 4) and injured pig spinal cords (n = 8) under in vivo conditions using a 4.7-tesla spectrometer. Spinal cords were injured by dropping a 20-g weight from 20 cm onto the surgically exposed cord surface. RESULTS: In vivo spectra of injured cords revealed a reduction in ATP, PCr, pHi, and an increase in Pi. In addition, a broad resonance that is likely to arise from myelin phospholipids was reduced significantly after injury. CONCLUSIONS: Phosphorus-31 NMR can be used to follow in vivo changes in high energy phosphates after injury and may have the potential to follow changes in myelin structure. This technique may prove important in the study of myelin breakdown after secondary, nonreversible spinal cord injury. Changes in high energy phosphates and pHi did not seem to parallel these putative changes in myelin structure.

Surgical treatment supposed natural history of the tethered cord with occult spinal dysraphism.

We retrospectively evaluated the pre- and postoperative course of 34 tethered cord patients with occult spinal dysraphism in an attempt to infer the natural history of this disorder and to determine the effectiveness of the surgical treatment. There were 32 cases with lumbosacral lipoma and 2 with tight filum terminale. The age at surgery ranged from 1 month to 47 years old. Eight patients, aged 1 month to 4 years old, were asymptomatic; 26 had neurogenic bladder (26 cases) or motor problems affecting the legs (8 cases). None of the patients older than 5 years of age were asymptomatic. Untethering of the spinal cord was performed in all cases. The postoperative follow-up period ranged from 5 months to 11 years. During these periods, 7 (88%) of the 8 asymptomatic patients remained neurologically intact, 6 (23%) of the 26 symptomatic patients showed improved symptoms, and 15 patients (58%) remained unchanged. These results indicate that the neurological symptoms will appear progressively in the tethered cord patients, and that prophylactic surgery should be considered as early as possible.

Surgical treatment of syringomyelia associated with spinal dysraphism.

Clinical and radiological features of syringomyelia in 15 patients with spinal dysraphism are reported. There were 8 patients with occult spinal dysraphism (lumbosacral lipoma) and 7 with spina bifida aperta (meningomyelocele). Syringomyelia with spinal dysraphism can be radiologically divided into two types according to the dysraphic state. The syrinx in the patients with occult spinal dysraphism occurred immediately rostral to the lipoma and was localized to the lower thoracic to lumbar levels, while in the meningomyelocele patients the syrinx extended from the cervical to the thoracic level. Large syrinx formation was recognized in 1 of the 7 occult spinal dysraphism cases and 3 of the 8 meningomyelocele cases. For syringomyelia with occult spinal dysraphism, 4 patients underwent syringo-subarachnoid shunting (S-S shunt, 2 cases) or syringostomy (2 cases) during an untethering operation. In the case of meningomyelocele, S-S shunts were placed in 2 patients. Collapse of the syrinx was achieved in all 6 patients who underwent S-S shunting or syringostomy. Decreased size of the syrinx was also noted in 3 occult spinal dysraphism patients who underwent untethering operations alone. In conclusion, a large syrinx in the case of spinal dysraphism should be surgically treated. S-S shunting is effective in both types of syringomyelia. Foramen magnum decompression may be an alternative method of surgical treatment for syringomyelia in patients with meningomyelocele.

Phosphorus-31 nuclear magnetic resonance spectroscopy of the spinal cord in the pig, rat, and rabbit.

RATIONALE AND OBJECTIVES: To ensure that contamination-free phosphorus-31 nuclear magnetic resonance (31P-NMR) spectra of the spinal cord could be obtained, a porcine model was adopted that provided a large cord sample and a greater area free from adjacent muscle tissue. METHODS: Phosphorus-31 NMR spectra were acquired from the porcine spinal cord under in vivo conditions using a 4.7-T spectrometer. Spectra also were collected from perchloric acid and lipid extracts, and excised freeze trapped samples of the rat, rabbit, and pig spinal cord. RESULTS: The in vivo spectrum showed resonances corresponding to adenosine triphosphate, phosphocreatine, inorganic phosphate, phosphomonoesterase, and phosphodiesterase as confirmed by extracts. In addition, a broad resonance was observed that was assigned to myelin phospholipids. CONCLUSION: Phosphorus-31 NMR spectra of the spinal cord revealed resonances common to brain tissue. Importantly, the existence of a previously undetected resonance, which is likely to correspond to myelin phospholipids, also is reported. This resonance may prove important in future studies monitoring changes in myelin in response to trauma and ischemia.

[Atlantoaxial dislocation with ventilatory insufficiency--report of two cases].

We performed electromyography and polysomnography in two cases of atlantoaxial dislocation with ventilatory insufficiency to determine the patients' respiratory patterns. The results showed that hypertrophic sternocleidomastoid muscles (SCMs) played an important part in their respiration. The diaphragm and intercostal muscles did not display marked electromyographic (EMG) activity, but the SCMs showed a great deal of phasic inspiratory activity during the daytime that decreased or disappeared during sleep. A 6-year-old boy with atlantoaxial dislocation related to spinal abnormalities was chiefly dependent on the SCMs for respiration and required mechanical ventilation when a sleep because the SCMs were completely inactive. A 4-year-old girl with atlantoaxial dislocation as the result of an automobile accident was partially dependent on the SCMs. She had no trouble breathing during the daytime, but polysomnography recordings showed recurrent hypopnea and desaturation during the night synchronous with decreased EMG activity of the SCMs. She also required mechanical ventilation to improve her long-term prognosis. Polysomnography should be performed in severe cases of atlantoaxial dislocation with respiratory failure in addition to routine respiratory function tests.