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We report a case of late-onset systemic toxicity due to ropivacaine over dose, and its successful reversal with 20% lipid emulsion (20% Intralipos). A 40-year-old woman, 40 kg, ASA-I, was scheduled for laparoscopy-assisted myomectomy of the uterus in which 40 ml of 0.375% ropivacaine was injected for bilateral US guided transversus abdominis plane block (TAPblock) under general anesthesia. Anesthesia proceeded uneventfully and she could go back to the ward 15 min later, but 3 hours after TAPblock, her blood pressure dropped to seventies and she became unresponsive. She also displayed clonic seizure/twitching of limbs. Immediately after diazepam 2 mg injection, clonic seizure disappeared and she could obey verbal commands. Within a few minutes clonic seizure was noted again, and she was hypotensive despite administration of vasopressors. A presumptive diagnosis of local anesthetic toxicity was made, and she received 100 ml bolus of 20% Intralipos. She regained consciousness with spontaneous return of blood pressure. She received a total of 230 ml 20% Intralipos, which was discontinued due to her rapid emergence with no further seizure episodes. This case suggests that early and sufficient use of lipid emulsion may lead to a good outcome. We recommend the immediate availability of lipid emulsion along with other emergency therapeutics at the ward after TAPblock.

A case of astrocytoma whose first clinical presentation was diagnostic dyspraxia was reported. A 38-year-old right-handed male experienced funny motion of his left hand triggered by voluntary movement of his right hand. One day, he tried to insert a coin into the vending machine with his right hand, then the left hand was against the other. One month after that event, he experienced headache and vertigo. On admission, there were no abnormal findings on neurological examination. On neuropsychological examination, he was cooperative, well orientated and attentive, and there were no callosal disconnection symptoms. Frontal lobe function tests were slightly impaired. T1-weighted MRI demonstrated irregular mixed signal intensity mass lesion extending from the genu to the body of the corpus callosum and the cingulate gyrus. This lesion was slightly enhanced with Gd-DTPA. Biopsy was performed and histological diagnosis was fibrillary astrocytoma. After irradiation and chemotherapy, he was discharged from the hospital without evident neurological deficit. About 20 cases of diagnostic dyspraxia have been reported and almost all of them were caused by cerebro-vascular disease. This is the first case of brain tumor who presented diagnostic dyspraxia.

In the previous reports, the theoretical background [corrected] and technical details of the Isocount scanning were described. Based on clinical experiences of various brain diseases, the newly developed scanning method was confirmed to be more useful than the conventional scintiscanning. Besides the new scanning method, a new display system was also developed for the sake of more precise analysis of the Isocount scanned data. This display method is called MULTILEVEL ANALYSIS or MULTILEVEL SLICING. In the present investigation, this method was applied to fortysix cases of brain tumors, including forty cases of supratentorial tumors and six cases of infratentorial tumors, positive rates being 95% and 67% respectively. Furthermore, as a measure of the quantitative investigation of the radioactive tracer uptake of the target area, the maximum uptake rate of the target area (RTmax.=Tmax./NTmean), and the deviation index (DI=DT/DNT) were introduced; Tmax., NTmean, DT and DNT are respectively defined as a maximum uptake of the target area, a mean uptake of the non-target area, a deviation rate of the target area and a deviation rate of the non-target area. They can be obtained from analysing the television figures of MULTILEVEL ANALYSIS. By this method, thirty-four cases of supratentorial tumors were studied. In cases of glioma (12 scans), meningioma (9 scans), and metastatic tumor (7 scans), the mean values of RTmax. were 1.26, 1.37, and 1.24 and the mean values of DI were 0.81, 0.68 and 0.60 respectively. In gliomas, the RTmax. and the DI were correlated with the degree of malignancy of the tumors. This quantitative analysis could be considered to be useful to foresee the nature of the brain tumor from the scintiscanning findings.

Among fifty-two angiographically examined patients of vertebro-basilar disorder, incidental intracranial aneurysms were found in five cases. These were four males and a female, ages ranging from 42-67 year old. Vertebro-basilar disorders were ischemic origin in three cases and hemorrhage in two cases. Locations of incidental aneurysms were the internal carotid artery, middle cerebral artery, anterior communicating artery and basilar artery. They were multiple in three cases. They were operated on radically, except one case whose status seemed to be untolerable to the operation. Intervals between strokes and operations were 51-81 days. In spite of successful operation, mild to moderate disturbances of consciousness appeared in three cases. In two cases they were subsided in a week, but in one case it persisted for two months. Fortunately, final results in all operative cases were good. These transient deterioration of consciousness level might probably be ascribed to vertebro-basilar insufficiency once subsided but resumed due to the operative affections. Through a small experience of four cases, three points would be discussed to prevent such hazards. 1) Extreme systemic hypotension as well as hypertension should be avoided during operation. 2) GOF might be an anesthesia of choice in such cases. 3) Operation should be favorably waited for more than six months after the ictus.

A 22-year-old woman was admitted following the sudden onset of severe headache and loss of consciousness. On admission, she was delirious with nuchal rigidity. A lumbar puncture showed bloody spinal fluid. Laboratory studies revealed no abnormalities. Her consciousness state became clear 2 days after the attack. Computerized tomography taken 7 days after the attack revealed intraventricular hemorrhage in the right trigonum. Emergent right carotid angiography was performed. The intraventricular extravasation of contrast media was shown in the region of the right trigonum. One hour after the angiography, she was semicomatose with left flaccid hemiplegia. Reexamination of computerized tomography revealed diffuse intraventricular hemorrhage and periventricular intracerebral hematoma in the right parieto-temporal lobe. Emergent operation was performed and intracerebral hematoma was extirpated. Good postoperative results were obtained after ventriculoperitoneal shunting 46 days after removal of the hematoma. In our review of the literature, intraventricular extravasation of contrast media through primary intraventricular hemorrhage has not been reported.U

It is well known that the gamma ray emitted by a radionuclide is a Poisson process, so its statistic nature should be taken in consideration when the scintiscanning is performed. But very few attempts have been done from this point of view. After examining in detail the imaging pulse charactristics, the authors introduced a mean for evaluating the fidelity of the collected data, and based on this criterion, pointed out some problems in the conventional scanning method and finally described a statistical way of improving the scintigram. In the present investigation, as a measure of the stochastic fidelity of the scanned data the relative deviation eplision(n) = sigma(n)/E(n) is introduced; sigma is the standard deviation and E(n) is the expectation value of the counting rate. In the conventional scanning in which the detector moves with a costant speed, the relative deviation varies from area to area according to the concentration of the radioisotope in the brain. In the so-called cold area of the brain scintigram, the relative deviation fluctuates remarkably because of a rather low density of radioisotope in this area.

Anticipating to get some new informations about the cerebral circulations of the comatous patients, two kinds of radioisotopic techniques were combined and applied to twelve unconscious patients of various etiologies. The first step was the conventional gas clearance method using xenon 133 as the indicator. Regional cerebral blood flows were measured at the six areas over each hemisphere. Immediately following this procedure, about 150 muCi of I-131 MAA (I-31 macroaggregated human serum albumin) were injected into internal carotid artery via the same catheter inserted already for the first procedure. Radioactivities of the head and lungs were measured and the relative shunt flow was calculated based on the formula already described elsewhere. Profil scanning of the whole body of the patient was also performed after the intracarotid injection of I-131 MAA. Consciousness states of the ten patients were all severely damaged and causes of the disturbed consciousness were various, including 5 of subdural hematoma, 2 of occlusive cerebrovascular disease, 2 of brain tumor and 1 of ruptured intracranial aneurysm. This investigation revealed the following results; 1) In all patients, regional cerebral blood flows were shown decreased over all areas detected. The regional cerebral blood flows could not be increased by 5% carbon dioxide inhalation, suggesting angioparalysis in these areas. 2) Graphical analysis of the clearance curves revealed triphasic flow pattern in rCBF in four cases. In three cases among the four, the intracarotid injection of I-131 MAA showed the radioisotope labelled particles were captured not only in the brain, but also in the lungs and the relative shunt flow calculated increased up to twice as much as normal controls. It indicates that some of the particles larger than the cerebral capillary size passed through the brain and were captured by the capillary net work of the lungs. From the above described data, it might be concluded that the initial rapid component of triphasic flow pattern in rCBF measurement does not represent the hyperemia of luxury perfusion of metabolic origin, but arteriovenous shunting blood flow, probably, through the precapillary thoroughfare channels which have been anatomically demonstrated by Hasegawa et al.

A case of the anterior choroidal artery aneurysm combined with the abnormal intracranial vascular net-work was reported. The patient was 43-year-old male who was attacked by subarachnoid hemorrhage in February 25th 1975. When he was admitted to our clinic 30 days after the ictus, his general status was good and the neurological examination showed no particular findings except only slightly accelerated deep tendon reflexes on the left side. Cerebrospinal fluid still remained xanthochromic although no nuchal rigidity was denoted. Based on the angiographic four vessel studies, the circulatory condition of the patient's brain was summarized as follows; the internal carotid arteries were stenosed or occluded between the C1 and C2 segment on both sides, and abundant collateral circulation was developed mainly around the circle of Willis making an angiographically peculiar vascular net-work in tha base of the brain. Another angiographic finding to be noticed was a berry aneurysm which originated from the distal part of the left anterior choirdal artery. No special treatment was performed on him. He was discharged without any neurological residuals. It would be difficult to find out any hemodynamic relationship between the occlusion of the internal carotid arteries and occurence of the aneurysm. But the abnormally dilated anterior choroidal artery might suggest that the vessel wall of this artery would be burdened in the abnormal distension stress due to the increased transaxial pressure in this artery. Unqder such a hemodynamically stressed state, it would be possible the aneurysm like outpouching of the vessel wall being developed in some fragile portion of the artery functioning as a prominent collateral circulation.

The authors reported a case of intracranial osteochondroma. A 52-year-old woman was admitted to Tokyo Women's Medical College hospital with seven years history of right visual disturbance and frontal heavy feeling. Neurological examination revealed merely right optic nerve impairment. A large mottled calcification in X-ray craniogram and a localized homogenous high density area illuminated by EMI scan in the right parasellar region were characteristic in diagnosis of osteochondroma. On April 21, 1976 a right fronto-temporal craniotomy was performed and the tumor tissue was removed partially. The pathological examination confirmed the diagnosis of osteochondroma (ossifying chodroma).

An attempt was made to collect the cerebrospinal fluid (CSF) of rat using a capillary phenomenon technique. Experiments were carried out in 76 rats anesthetized with pentobarbital sodium (Nembutal, Abbot. 50 mg/kg IP). The midline incision in the occipital region was made from 0.5 cm anterior to interauricular line of 4 cm in length. Exposing the atlanto-occipital dura mater by separating the nuchal muscles, the CSF was collected with a heparinized microtube (MICROPET. Bection, Dickson and Company) through a small hole made by a 18G syringe needle. Thus, 0.05-0.05 ml of the CSF could be readily obtained without mixture of the blood in 64 cases out of 76 trials, 84%. This simple technique is a useful way to get a small amount of CSF from little animals, such as rats.

The purpose of this study is to investigate salient diagnostic features of the brain abscess in RI brain scanning. In 27 patients with brain abscess, 37 scannings were performed in the various stages of their clinical courses. The results were positive in all cases. Among 27 cases, ten cases were investigated by means of the ISOCOUNT SCANNING SYSTEM, the technical detail of which was reported previously. It was proved that the isocount scanning method combined with the multilevel analysis was more sensitive diagnostic aid than the conventional RI scintigraphy. Using the newly developed method, it was not difficult to diagnose the brain abscess in its early stage, even in the stage of presuppurative cerebritis. Doughnut sign was seemed to be more frequently visualized by this method. Surgical indication of the brain abscess was discussed from nucleomedical view point, and it was emphasized that so-called doughnut sign in brain scanning would indicate the appropriate stage of the brain abscess to be operated on.

To clarify the pathogenesis of normal pressure hydrocephalus (NPH), quantitative measurement of CSF dynamics was attempted using RI techniques. In this study results concerning RI ventriculography and RI transfer test from CSF to plasma were reported. "Barrier ratio" and regional cerebral blood flow study in NPH will be reported elsewhere. Fifty-three patients with chronic communicating hydrocephalus wer devided into two groups. Thus, twenty-seven cases were diagnosed as NPH according to clinical symptoms and signs, and others were considered as mere chronic communicating hydrocephalus without any NPH characteristics. Results are as follows: 1) 169Yb--DTPA ventriculography; In NPH group, there was longer retention of RI injected into lateral ventricle, and RI activity was not detected in the cisterna magna 60 minutes after the injection. These findings show remarkable delay of CSF flow in NPH patients. 2) Transfer test of 169Yb--DTPA from CSF to plasma; Immediately after the RI injection, Transfer ratio of RI activity from CSF to plasma was measured. It was revealed that intraventricular RI was more rapidly transfered to plasma in NPH group compared with in the control group, suggesting accelerated trans-ependymal absorption of RI in NPH group.

A 15-year-old girl was admitted to our clinic on July 16, 1985 with the epilepsy which had been resistant to various anticonvulsant therapies. At the age of 10 years automatism seizure, characterized by purposeless movement of arms and head of which the patient was unaware, began to occur and became as frequent as two to three times each day. From the age of 13 years, there were also grand mal seizures several times a year in spite of medical treatment. She had normal delivery and no history of febrile convulsion. There was no family history of epilepsy or mental disease. When examined on admission, she had normal personality and intelligence. There was no neurological abnormality. She complained of sleepiness and hirsutiness. Fit of automatism occurred two to three times a day during admission, though the blood levels of anticonvulsant drugs such as phenobarbital, phenytoin and carbamazepine reached to therapeutic concentration. EEG examination including infratemporal lead recording showed right temporal spike focus. But all the neuroradiological studies such as skull X-rays, CT, cerebral angiography and magnetic resonance imaging failed to show abnormal finding. Right temporal lobectomy was carried out under general anesthesia on Aug 22, 1985, and anterior two-thirds of the middle and the inferior temporal gyri were resected deeply to anterior hippocampus. To the naked eye, no abnormal finding was noted during the operation. In the surgical specimen, macroscopically nothing abnormal was found. Microscopically, serial sections of the lobe revealed clusters of oligodendroglial cells in cortical to subcortical region of the medial basal part of the temporal lobe.(ABSTRACT TRUNCATED AT 250 WORDS)

Although the cerebral blood flow dynamics in cerebral infarction has already been studied by many investigators, the CSF flow dynamics in cerebral infarction has not been well discussed. The purpose of this paper is to investigate CSF flow dynamics in chronic cerebral infarction by RI cisternography and our new quantitative method. In 12 patients with cerebral infarction, the flow of CSF was estimated following intrathecal injection of 169Yb-DTPA or 111In-DTPA. In this study, in addition to the conventional cisternograms, quantitative evaluation of CSF flow was performed in 6 patients by our method. Our previous work included the quantitative CSF flow dynamics in 26 various cerebral disorders using RI Anger camera. This method consisted of following procedure: 30 minutes after RI injection, RI activity was studied continuously for 30 minutes, afterwards playing back the record to calculate the changes of RI activity in the optimal regions of interest. These operations were performed with Anger camera, accessory digital ratemeter and tape-recorder. The changes of RI activity which appeared to be linear is called flow rate in our study for convenience. In this report, the region of interest was selected at Sylvian cistern. 6 patients had abnormal cisternograms consisting of reflux of tracer into the ventricle and delayed migration of tracer to the basal cisterns and diminished flow of tracer in the affected hemisphers. In 5 patients whose cisternograms could not demonstrate the laterality of RI perfsion over the cerebral hemishere, a marked difference of flow rate between right and left Sylvian cisterns was found. These findings probably indicated the correlation between cerebral blood flow dynamics and CSF flow dynamics in cerebral infarction. Moreover, it was confirmed that our method could be of clinical use to evaluate CSF flow dynamics quantitatively. The possible mechanisms of CSF flow disturbance in the affected hemisphere following cerebral infarction was discussed.

In the previous report the theoretical background and technical details of the isocount scanning were described. Based on clinical experiences of various brain diseases, the newly developed scanning method was confirmed to be more useful than the conventional scintiscanning. Besides the new scanning method, a new display system was also developed for the sake of more precise analysis of the isocount scanned data. This display method is called multilevel analysis or multilevel slicing of the scanned data. In the present investigation, this method was applied to thirty-two cases of cerebrovascular diseases, including seven cases of cerebral arterio-venous malformation, four cases of hypertensive intracerebral hemorrhage and twenty-one cases of cerebral infarction, positive rates being 86%, 100% and 90% respectively. In case of arterio-venous malformation, minimum size detected by the isocount method was 2 cm in diameter. To twenty one cases of the cerebral infarction, total thirty two scanning examinations were performed, including postictal follow up studies. It is often said that it is two or three weeks after the ictus when the infarcted cerebral lesion is most clearly detectable by the scintigraphic procedures, presumably due to focal neovascularizations which may occur in the lesion most prominently at this postictal stage. Contradicted to the current concept, our experiences show that abnormal dot accumulations are recognized in the scintigrams even at the earlier stage, thus among five cases of cerebral infarction scanned within a week after the ictus positive figures were obtained in four cases, two of which were examined within two days after the ictus. Focal breakdown of blood brain barrier at the acute stage is considered to be responsible for the early positivity in cerebral infarctions. In eight cases among twenty one cerebral infarctions angiographies failed to demonstrate the vessel occluded. The isocount scanning method, however, succeeded in getting positive results in seven of the eight cases. It will be emphasized that the isocount scanning is a preferable diagnostic procedure in the cerebrovascular diseases, especially when the angiography is hesitated to be performed because of the patient severely affected.

In the previous study, quantitative analysis of RI ventriculography was reported in fifty-three cases with chronic communicating hydrocephalus. In this study, according to the same criteria as that of previous report, fifty-three cases were divided into two groups, namely NPH group (twenty-seven cases) and control group, which were considered as mere chronic communicating hydrocephalus without and NPH chalacteristics. (twenty-six cases). Results of "barrier ratio (B.R.)" measurement and regional cerebral blood flow study in these cases are as follows: 1) "Barrier ratio" using of 99mTcO4-: Concerning about B.R. of 99mTcO4- there was no significant difference between NPH and control group. However it tends to be that shunt surgery is not so effective in NPH cases in which B.R. shows abnormally low value. 2) rCBF by 133Xe clearance method: Regional cerebral blood flow was diffusely decreased in NPH patients, especially in its frontal area, suggesting the frontal area would be more severely damaged in NPH cases. These findings leads us to the conclusion that whether the shunt surgery might be effective or not depends on severity of cerebral dysfunction and the cerebral dysfunction is clearly evaluated by RI technique mentioned above.

It is well known that the permeability of the blood brain barrier and blood cerebrospinal fluid barrier changes more or less in various diseases of the central nervous system. At present, thee is no clinically available index which reflects the alteration of the permeability of the blood brain barrier and blood cerebrospinal fluid barrier. The brain scintiraphy is an examination which detects a breakdown in the blood brain barrier, its clinical usefullness is limited only in a localized and extremely pathological proces of the brain. In this report, a cerebrospinala fluid isotope measurement comined with the brain scintigraphy was presented as a clinical examination for blood brain barrier function. Thirty minutes prior to brain scintigraphy, potassium perchlorate (4 mg/kg) was given orally to reduce the accumulation of 99mTc04-in the choroid plexus and to minimize iradiation for tr other organs. Spinal tap was performed two hours after injection of 99mTc04- according to Haines's method...