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We report a case of bacterial aneurysm complicated by severe infectious endocarditis. A 34-year-old man developed idiopathic fever and general fatigue persisting for a month. He was admitted to our institution, and examinations revealed severe bacterial endocarditis with vegetation at the mitral valve and mitral incompetence. Right after admission, he suddenly developed acute cardiac infarction and cardiac arrest due to occlusion of the coronary artery by emboli from vegetation of the mitral valve. After achieving a good recovery, magnetic resonance (MR) imaging demonstrated an unruptured bacterial aneurysm at the distal branch of the left middle cerebral artery (MCA) supplying the left parietal lobe 5 days after admission, and T2* weighted images demonstrated multiple signal loss lesions, which were suspected of being thrombosed bacterial micro-aneurysms or micro-vasculitis. Although there was a risk of aneurysm rupture, we decided to proceed with mitral valve replacement by an artificial heart valve made of carbon, and repeatedly observed an unruptured bacterial aneurysm by serial MR imaging and angiography. Due to the preceding cardiac surgery, we were able to completely cure the severe infection and prevent new embolic showers. Under administration of antibiotics, the bacterial cerebral aneurysm did not increase over a period of 4 weeks, and finally the aneurysm disappeared about 6 weeks after admission. Although the timing of treatment of an unruptured bacterial aneurysm and cardiac surgery for infectious endocarditis associated with a bacterial cerebral aneurysm are controversial, we think that proceeding with cardiac surgery and observing the unruptured bacterial aneurysm by repeated MR imaging and angiography under administration of antibiotics was an appropriate strategy in this case.

We report 2 cases of hypoxic ischemic encephalopathy with atypical findings on computed tomographic (CT) and magnetic resonance (MR) imaging for the acute to subacute stage. Case 1: A 78-year-old man with larynx cancer suffered cardiac arrest after suffocation. Cardiopulmonary resuscitation, was performed; the patient then went into a deep coma and also developed severemyoclonus. CT scans on day 0 and day 3 after the arrest revealed no abnormalities MR imaging was performed on day 13 to evaluate cerebral anoxia; however, no abnormal findings were obtained. Since no abnormalities were detected both on CT and MR imaging, we expected that the prognosis would be good; however, the patients did not recover from coma and remains in a persistent vegetative state. Case 2: A 54-year-old man developed cardiac arrest after anaphylactic shock caused by insect bite. After cardiopulmonary resuscitation, the patient lapsed into a deep coma. CT scans performed on day 1 and 3 after the cardiac arrest revealed slight subarachnoid hemorrhage at the surface of the right cerebral cortex along the falx cerebri. MR images obtained on day 10 demonstrated slight hemorrhage at the surface of right cerebral cortex, but no abnormalities in basal ganglia, thalamus, cortex, and white matter. The transient damage of the blood brain barrier caused by hypoxia and ischemia was thought to induce the slight subarachnoid hemorrhage after cardiopulmonary resuscitation. The patient demonstrated early recovery and was almost completely recovered with slight agnosia. MR imaging to rule out hypoxic-ischemic encephalopathy may not have been timed appropriately in both the case, our radiological findings are usual as compare to the findings presented in other similar reports. The variations in the findings of CT and MR imaging in the case of hypoxic-ischemic encephalopathy should be clarified, and the prognosis and management of this condition should be planned on the basis of not only the neuroradiological images but also the neurological signs and symptoms.

Many neurosurgeons prefer to use intraoperative computed tomographic (CT) scanning, when possible, to check whether there is residual lesion or unexpected bleeding. We report a practical intraoperative CT imaging system using a high-speed CT scanner installed in the operating room along with a digitally controlled neurosurgical operating table. We designed a rail-track system to mobilize the CT gantry. The gantry is fixed onto a motorized carrier that can be moved smoothly on a rail-track embedded in the floor and with a maximum reach of 2.85 m from the room's wall to the operating table. The longitudinal motion of the operating table is easily adjusted by a foot switch from manual control to automatic control directly from the CT scanner's computer like an ordinary CT scanner bed in increments of 2, 5 or 10 mm during CT scanning. Either a carbon-made radiolucent head frame or carbon-made head plate is used as a headrest. Using this CT scanner system, pre- and intraoperative CT scannings were performed on 46 patients with brain tumors, cervical lesions or other intracranial lesions. We could operate on the patient with enough working space between the mobile CT gantry and the operating table for microneurosurgery. We could obtain intraoperative CT imaging of a patient on the operating table while the surgical wound remained open, the surgical drapes kept in place, and the surgical position unchanged, saving time in intraoperative CT scanning and preparation for further surgery when needed. This intraoperative CT imaging system installed in the operating room should be useful for neurosurgery.

Cervical anterior fusion with iliac bone crest has become a popular surgical technique for cervical spondylotic disease. Since about 10 years ago, we have substituted hydroxyapatite ceramic spacer for autologous graft because of postoperative painful hip syndrome. Fourteen patients who underwent cervical anterior fusion with ceramic spacer were evaluated by plain radiographs for over eight years postoperatively. In six among the fourteen patients plain films demonstrated minimal stenosis of intervertebral disc height, of which the ratio ranged from 15% to 28% (mean 22%). The increase in mobility of the adjacent segment after fusion was noted in ten of the fourteen patients, although the ratio ranged only between 12% and 24% (mean 18%). In none of all the patients did dynamic plain films show cervical instability such as slippage and swan neck deformity. It seems that anterior fusion with ceramic spacer is a useful and safe method for a cervical spondylotic disease.

The influence of total body hyperthermia (TBHT) on normal brain tissue was studied in 40 dogs. The dogs were anesthetized with sodium thiopental (10 mg/kg/hr) intravenously, and were ventilated by artificial respirator. The TBHT was induced by extracorporeal circuit in cooperating a heat exchanger. Rectal temperature was raised to 41.5 degrees C and maintained at 41. 5 -42.0 degrees C for 2 hr (HT period) and was then fallen to normothermia by cooling, Regional cerebral blood flow (CBF) was measured by hydrogen clearance method before heating, during and after TBHT treatment. Brain temperature, rectal temperature, intracranial pressure (ICP), brain tissue pH and electroencephalography (EEG) were monitored continuously during TBHT. Histopathological changes of the brain tissue were studied in dogs killed just after TBHT and 2 weeks after TBHT. Autoregulation of the CBF during HT period was assessed by measuring the regional CBF and the ICP at a state of induced hypo- or hypertension. The brain temperature (at the depth of 5mm under the brain surface) was usually 0.6 degrees C lower than the rectal temperature during HT period. The regional CBF increased from 38.1 +/- 6.5 (mean +/- SD) to 49.1 +/- 9.8ml/100 g/min by raising rectal temperature, and it recovered to a normal value after cooling. The ICP increased from 10.3 +/- 4.2 to 16.8 +/- 3.4 mmHg by raising rectal temperature, and it returned to a normal value after cooling. Brain tissue pH decreased from 7.33 +/- 0.02 to 7.17 +/- 0.09 rapidly when the rectal temperature reached 41.0 degrees C, and then returned to a normal value gradually after the start of cooling.(ABSTRACT TRUNCATED AT 250 WORDS)

Central nervous system is rarely involved in progressive systemic sclerosis (PSS) unless there are concomitant abnormalities in renal or lung function or hypertension. A 72-year-old woman with typical PSS developed cerebellar bleeding. Medical history records revealed, she had noted the onset of Raynaud's sign on her upper extremities at the age of 37. This was followed by necrosis and repeated infection, and as a result, shortening of her fingers in her 40's. The disease progressed and involved lower extremities, and then face and body in her 50's. Aortic valve stenosis was diagnosed at 69 year old, cardiac myopathy at 70 and at the age of 71 infectious dermatitis in both inguinal regions. Mild anemia, hypoalbuminemia and the decrease of serum Fe were discovered in June 1988. At the same time, prolonged ESR, positive C-reactive protein, RA, and anti-nuclear-antibody were also noticed. A chest roentgenogram revealed pulmonary fibrosis. Systemic hypertension was not noticed on the clinical course. She developed an onset of vertigo and vomiting in the morning of August 8, 1988. Consequently, she was brought to our hospital. She was alert but a physical examination showed a swallowing disturbance, dysarthria, right cerebellar ataxia, nystagmus and hypertension (192/100 mmHg). A CT examination on admission revealed a slightly low density area in right cerebellar hemisphere without mass effect. She was treated with dextran and mannitol and her condition improved on the 6th day of her admission. She was alert and blood pressure calm down to 120/70 mmHg without the use of anti-hypertension drugs on August 21.(ABSTRACT TRUNCATED AT 250 WORDS)

Eighteen patients were studied for cerebral blood perfusion abnormalities using N-isopropyl I-123 p-iodoamphetamine (IMP) and rotating dual gamma camera emission computed tomography (ECT). All were stroke patients, 10 with cerebral vasospasm after an aneurysmal rupture, 3 with an occlusion of the middle cerebral artery, 2 with an occlusion of the internal carotid artery (IC), one with an IC stenosis, one with Moyamoya disease and one with RIND. Four patients had extracranial-intracranial (EC-IC) bypass operations. In three of them, CBF studies were done before and after bypass surgery. An arterial line was placed in the left radial artery and connected to a Harvard pump. IMP (1.5-3 mCi) was injected into an arm vein while at the same time an arterial blood sample was withdrawn at a constant speed for 5 minutes. Scanning was started 35 minutes after IMP injection. After a scan, multiple transverse, coronal and sagittal section images were reconstructed with a minicomputer. We determined the values of regional CBF in the regions of interest using an image. Transmission computed tomography (CT) studies were performed on the same day. In eight patients, CBF study by 133Xe inhalation method (NOVO cerebrograph) was done. ECT showed diffuse low perfusion in two patients and focal low perfusion in 16 patients while CT showed abnormalities in 9 patients (50%). ECT abnormalities were more extensive than CT abnormalities. The values of rCBF in the superficial brain determined by ECT were similar to those examined by the inhalation method (ISI). Significant increase in rCBF was observed after the bypass operations.(ABSTRACT TRUNCATED AT 250 WORDS)

A case of benign chondroblastoma extending from the nasal cavity to the frontal region, was reported. A 1-year and 9-month old girl was admitted to our hospital in April 1981 because of generalized convulsion. On admission, she was intact neurologically and had It. nasal obstruction and It. eye discharge. Her laboratory examinations, including serum electrolytes and A1-P, were all in normal range. Plain skull X-P showed marked calcification from midfrontal region to the nasal cavity, and destruction of the frontal base especially in It. side. Plain CT showed isodensity mass with spotty calcification in the nasal cavity and marked high density mass in the frontal region. By contrast enhancement, nasal mass was markedly enhanced and new enhanced mass appeared around the intracranial calcification. Lt. ext. CAG showed the enlarged middle meningeal artery which is the feeder of the tumor, fine tumor vessels and slight tumor stain. Lt. int. CAG only showed the mass effect. After three-stage operation of bifrontal craniotomy, sublabial transnasal approach and rhinotomy, all the tumor was removed and she was discharged with no neurological deficits. The tumor was well demarcated and consisted from solid, cystic and calcified region. The solid region was grayish and easy-hemorrhagic. Histological examination revealed characteristic features of benign chondroblastoma, such as diffuse proliferation of polygonal or round cells, foci of chondroid matrices, scattered polynuclear giant cells and some mitosis.

A 33-year-old male was admitted to the Department of Neurosurgery, Fukui Medical School with a complaint of headache. There were no neurological deficits on admission. Craniogram demonstrated a so-called "phantom sella". A computed tomography revealed a high density mass lesion and the mass was enhanced well, that mainly extended from the sella to the left middle cranial fossa. The left carotid angiogram revealed an avascular mass lesion extending from the sella to the left middle cranial fossa. Pituitary function tests revealed an extremely high serum prolactin (PRL) levels (70, 100 ng/ml). PRL response to TRH was delayed in peak and the high level continued. Serum PRL levels elevated to 90, 800 ng/ml at 180 min after injection of TRH. A biphasic response was demonstrated in response to CB-154 suppression test to PRL secretion, that is, CB-154 stimulated PRL release initially (up to 90 min) and suppressed thereafter. Serum PRL levels (178, 400 ng/ml) reached to peak about 90 min after CB-154 administration. Response of growth hormone (GH) and adrenocorticotropic hormone (ACTH) to insulin were also impaired. Craniotomy was performed. The tumor was partially removed and was diagnosed as a prolactinoma histologically. Tumor tissue removed was subjected to the monolayer culture and electron microscopic study. Their observations demonstrated hyperactive PRL secretion of the individual cells. A total dose of 5,000 rads was irradiated postoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)

Release of arachidonate metabolites from isolated canine cerebral arteries into perfusing medium were estimated using radioimmunoassay (RIA) in vitro. The cerebral arteries were isolated from dogs sustained experimental subarachnoid hemorrhages (SAH) and the results were compared with that of normal canine cerebral arteries. The amount of 6-Keto-PG F1 alpha (stable metabolite of PGI2) and PGE2 released from normal cerebral arteries were 455 +/- 84 (n = 7) and 177 +/- 72 (n = 8) ng/min/g dry weight (mean +/- SEM), respectively. Among other arachidonate metabolites, TXB2 (stable metabolite of TXA2), PGF2 alpha, PGD2 were also measured, but release of these arachidonate metabolites were little compared with PGI2 or PGE2. The amount of 6-Keto-PGF1 alpha and PGE2 released from the cerebral arteries subjected to subarachnoid hemorrhage were 110 +/- 34 (n = 6), 169 +/- 40 (n = 6) ng/min/g dry weight respectively. In SAH group, release of 6-Keto-PGF1 alpha had diminished remarkably, but no remarkable quantitative change were seen among other arachidonate metabolite between normal and SAH groups. The diminution of PGI2 release in the cerebral artery subjected to SAH may be involved in the pathogenesis of cerebral vasospasm. The release of PGs from canine pial arteries induced by the exposure of the pial arteries to red blood cell hemolysate was also estimated by RIA. The release of PGE2 tended to increase following to exposure to hemolysate but no other arachidonate was increased.

Isotope cisternography was performed and ventricular system size was evaluated on serial computerized tomography scans in 57 patients with plateau waves in their continuous intracranial pressure recordings. The patients were assigned to three groups based on the presence or absence of communicating hydrocephalus and their intracranial pressure level: the first group comprised 23 patients with high intracranial pressure and without hydrocephalus, resulting from supratentorial brain tumor, benign intracranial hypertension and superior sagittal sinus thrombosis; the second group included 22 patients with either high intracranial pressure or communicating hydrocephalus, resulting from intracranial aneurysmal rupture: and the third group was composed of 12 patients with normal intracranial pressure and communicating hydrocephalus, resulting from intracranial aneurysmal rupture. Plateau waves in the first group patients were characterized as large plateau like formations recurring at varying intervals, with a height of 50-100 mmHg and a duration of 10 to 30 minutes. Plateau waves in the second group patients had a height of 20 to 60 mmHg and a duration of 3 to 15 minutes. The waves in the second group patients were smaller in amplitude and shorter in duration as compared with the waves in the first group patients. Plateau waves in the third group patients had an amplitude of 15 to 40 mm Hg and a duration of 3 to 10 minutes. They were the smallest in amplitude and the shortest in duration as compared with the plateau waves seen in the first and the second group patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The intracranial pressure, systemic blood pressure and compressed spectral array in EEG monitoring were studied in three patients with typical plateau waves in continuous intracranial pressure recordings. Two patients with brain-tumor and one patient with aqueductal stenosis were included. The intracranial pressure was recorded through an indwelling ventricular catheter attached to a pressure transducer. The systemic blood pressure was recorded through an intraarterial catheter placed in the femoral artery or the dorsalis pedis artery. To obtain continuous and compressed spectral array in the EEG, Berg-Fourier Analyzer by the OET-Biomedica Company of Italy was used. Simultaneous recordings of the intracranial pressure, systemic blood pressure and EEG spectral analysis were made for 180 minutes in each patient. During the plateau waves, the systemic blood pressure did not rise in spite of a marked increase in intracranial pressure, resulting in a marked decrease in the cerebral perfusion pressure. The patients, however, showed no clinical symptoms resulting from ischemia of the brain, such as vasopressor response and impairment of consciousness, but complained only headache. The spectrograms in these patients were characterized by a constant and predominant activity in the alpha or high frequencies. This structural aspect was retained throughout the continuation of plateau waves. The power of low frequencies only appeared transiently. The results suggest that some mechanisms producing and maintaining the fast and/or alpha wave activity may participate in the recurrent appearance of plateau waves.

Regional cerebral blood flow (rCBF) was measured in 49 patients with surgically treated hypertensive intracerebral hemorrhage (putaminal hemorrhage 27: thalamic hemorrhage 22). The hematoma evacuation was performed within 14 days after the hemorrhage. For the measurement of rCBF, the intracarotid xenon-133 injection method was used. Two rCBF studies were performed on all patients, the first giving the resting state of the brain perfusion, the second after Prostaglandin E1 (PGE) administration into the internal carotid artery 10 minute after the first study. (PGE was administered 10 micrograms in 5 minutes.) In all patients blood pressure and arterial carbon dioxide tension were examined before and after each CBF study. The evaluation was made by comparing the rCBF maps obtained before and after PGE administration. (A rate of rCBF increase was calculated by dividing each rCBF value obtained after PGE administration by each rCBF value obtained before PGE administration (control value), and the ratio was multiplied by 100.) The PGE-induced reaction patterns were divided into four; the first is the diffuse increase pattern, characterized by a diffuse increase of rCBF values in the hematoma-evacuated area and the surrounding brain; the second is the diffuse decrease pattern, characterized by a global decrease of rCBF values in the hematoma-evacuated area and the surrounding brain; the third is the pattern of intracerebral steal effect, characterized by a decrease of rCBF in the hematoma-evacuated area and an increase of rCBF values in the surrounding brain; and the fourth is the pattern of inverse cerebral steal effect, characterized by an increase of rCBF in the hematoma-evacuated area and a decrease of rCBF in the surrounding brain.(ABSTRACT TRUNCATED AT 250 WORDS)

The intracranial pressure, systemic blood pressure, respiratory pattern and heart rate were studied polygraphically in five patients with plateau waves in continuous intracranial pressure recording. Three brain-tumor patients and two benign intracranial hypertension patients were included. The intracranial pressure was recorded through an indwelling ventricular catheter attached to a pressure transducer. The systemic blood pressure was recorded through an intraarterial catheter placed in the femoral artery. The recordings were made from 18 to 40 hours and a total of 770 plateau waves were examined in this study. The systemic blood pressure showed little or no change in spite of a marked rise in intracranial pressure. The respiratory alterations were always noted during the plateau waves. This respiratory changes during the plateau waves were assigned into three patterns. The first was the suppressed respiratory pattern during the entire course of the plateau waves (Type I): the second was the pattern characterized by the initial suppression followed by the late hyperventilation (Type II); and the third was the hyperventilation pattern during the entire course of the plateau waves (Type III). The pattern of Type I was noticed in 65% of the observed plateau waves, the pattern of Type II in 23%, and the pattern of Type III in 12%. The heart rate decreased in most plateau waves, but there was little change in the heart rate in some plateau waves.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors studied brain blood flow with single photon emission computed tomography (SPECT) in two patients with plateau waves. The intracranial pressure and blood pressure were also monitored continuously in these patients. They included one patient with brain-tumor (rt. sphenoid ridge meningioma) and another with hydrocephalus after subarachnoid hemorrhage due to rupture of lt. internal carotid aneurysm. The intracranial pressure was monitored through an indwelling ventricular catheter attached to a pressure transducer. The blood pressure was recorded through an intraarterial catheter placed in the dorsalis pedis artery. Brain blood flow was studied with Headtome SET-011 (manufactured by Shimazu Co., Ltd.). For this flow measurement study, an intravenous injection of Xenon-133 of about 30 mCi was given via an antecubital vein. The position of the slice for the SPECT was selected so as to obtain information not only from the cerebral hemisphere but also from the brain stem: a cross section 25 degrees over the orbito-meatal line, passing through the inferior aspect of the frontal horn, the basal ganglia, the lower recessus of the third ventricle and the brain stem. The results indicated that, in the cerebral hemisphere, plateau waves were accompanied by a decrease in blood flow, whereas, in the brain stem, the blood flow showed little change during plateau waves as compared with the interval phase between two plateau waves. These observations may explain why there is no rise in the blood pressure and why patients are often alert during plateau waves.

A sign of descending tentorial herniation (DTH) on computed tomography (CT) in 48 patients with putamenal hemorrhage was examined in the acute stage. Correlation between the DTH sign and prognosis for survival was studied in two groups; a conservative group and an operative group. Patients were grouped according to the presence or absence of DTH sign on CT. Grade 0: no herniation sign; Grade I: an encroachment upon the lateral aspect of the suprasellar cistern (impending herniation); Grade II: widening of the crural and ambient cistern on the same side as hematoma (actual herniation); Grade III: effacement of the cisternal space at the tentorial level (advanced stage of herniation). Twenty-one patients (44%) with Grade 0 DTH sign showed a good prognosis in both conservative and operative groups. Six patients (13%) with Grade I DTH sign also showed a good prognosis in both the conservative and the operative groups except one patient with anisocoria. There were 14 patients (29%) with Grade II DTH sign. Three of them who were treated conservatively showed only mild impairment of consciousness at the initial phase, but became worse 3-4 hours later. In the remaining patients who showed severe impairment of consciousness from the beginning of the illness, prognosis was poor except for patients with hematoma evacuation. Seven patients (15%) with Grade III DTH sign had poor prognosis both in the conservative and the operative groups. It is suggested that, in the acute stage of patients with putamenal hemorrhage, operative procedure should rapidly be performed not only for the clinical herniation sign but also for the DTH sign on CT even if the patients showed no clinical sign and only impairment of consciousness.

A 29-year-old man with Cockayne's syndrome (CS), presenting reversible ischemic neurological deficit is reported. In his past history, hearing disturbance developed at 6 years old and visual disturbance at 12 years old. His parents have consanguinious marriage. He came to our hospital complaining of right-sided hemiparesis and speech disturbance. He was 115.8 cm tall and his weight 20 kg. The characteristic manifestation of CS, i. e., dwarfism, mental retardadation, cachectic feature, retinal atrophy, neural deafness and calcification of bilateral basal ganglia were all noticed. A CT scan on admission revealed marked brain atrophy as well as the intracranial calcifications, while no lesions compatible with his neurological findings were detected. Cerebral ischemic state was mostly suspected. Following up with conservative therapy by the use of fibrinolytic agent, his neurological deteriorations disappeared on the 4th hospital day. Cerebral angiograms showed stenotic lesions of both C1-C2 portion of the left internal carotid artery and the right middle cerebral artery, and the aneurysm in the right internal carotid artery. Such atherosclerotic vascular change as observed in the cerebral angiograms in this case have progressed rapidly for his age. In this case, diabetes mellitus and hyperlipoproteinemia such as increased total cholesterol, increased triglyceride, decreased HDL and increased apoprotein B and C II were complicated for the risk factor of the atherosclerosis. It's controversial that early progress of atherosclerosis is due to ideopathic original feature of CS or to the secondary change from these complications.(ABSTRACT TRUNCATED AT 250 WORDS)