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In cervical radiculopathy, neurological findings for the upper extremities and the responsible level of the radices have been precisely detailed. However, in cases of cervical spondylotic myelopathy, it is not always easy to determine the responsible level of the cervical spine solely based on neurological findings. To disclose characteristic neurological lesions of the upper extremities, if any, for different locations of disc disease, 49 patients with cervical disc protrusion at single levels, confirmed by magnetic resonance imaging, were analyzed. Thirty-six patients demonstrated long tract signs (LTS) concomitant with segmental signs in the upper extremities, and 13 patients had no LTS. Except for deep tendon reflexes and the extent of dysesthesia in the upper extremities, there were no characteristic neurological findings, such as muscle atrophy, loss of muscle strength, extent of hypalgesia, or hypesthesia, pointing to the responsible compression site. In the 13 patients without LTS, the extent of dysesthesia and diminution of deep tendon reflexes proved to be completely in agreement with results for radiculopathy: 9 had protruded discs at the C56 level and described dysesthesia in the thumb and the index finger with deep tendon reflexes in the biceps and brachioradialis being diminished. The remaining 4 had protruded discs at the C67 level and described dysesthesia in the middle finger. Their deep tendon reflexes in the triceps were diminished. A clear contrast was observed for the patients with LTS. Four out of 36 patients had C34 protruded discs and did not complain of dysesthesia in any digits. Their deep tendon reflexes were exaggerated in all muscles in the upper extremities.(ABSTRACT TRUNCATED AT 250 WORDS)

We report here a case with meningioma showing malignant transformation in its course of multiple recurrences. A 59-year-old woman developed a right-sided hemiparesis in June, 1982 and CT scan disclosed a parasagittal well-enhanced mass. The tumor was subtotally removed (Simpson grade III) by an operation in September, 1982. Histological findings of the tumor were consistent with a meningothelial meningioma but showed no malignant features, such as high cellularity, necrotic foci, high mitotic rate, or nuclear pleomorphism. However, the tumor did invade the underlying cerebral cortex. In August, 1986, a recurrent tumor was detected by CT scan and was removed (Simpson grade III). The tumor tissue at the second operation showed the same histological features as the first specimen. In September, 1990, the patient developed multiple intracranial recurrences. There were three tumor nodules, all of which were removed. Histologically, significant histological differences between the second and the third operative specimens were found. In the last tumor tissue, one nodule showed a papillary pattern. In the other tumor nodules, each tumor cell had proliferated separately instead of adhering to other tumor cells to form a syncytium. This histological pattern was consistent with an epithelial meningioma described by Cushing and Eisenhardt in 1938. The papillary portion of the tumor was stained with monoclonal antibody Ki-67 in frozen section. The labelling index was 9.7%, which was as high as malignant meningioma. Electron microscopic examination of the papillary portion of the tumor showed that the tumor cells had irregular nuclei, interdigitations between the adjacent plasma membranes and a few ill-developed desmosomes.(ABSTRACT TRUNCATED AT 250 WORDS)

We have recognized a characteristic distribution of cisternal blood in 10 (43%) of 23 patients with subarachnoid hemorrhage (SAH) of unknown etiology. On the initial CT examination undertaken within 48 hours of the onset, blood from 10 patients was found to be more densely distributed in the cisterns around the brainstem. In this study, clinical characteristics and CT findings in those 10 cases were carefully evaluated and the CT findings were compared to those of 416 patients with aneurysmal SAH (anterior circulation aneurysm 368 cases, posterior circulation aneurysm 48 cases). There were seven men and three women, with an age ranging from 39 to 64 years (average age, 50.6 years). The follow-up period ranged from 4 to 45 months (average follow-up period, 23 months). Neurological grade (WFNS) on admission was I in 9 cases and III in one case. None of the patients suffered symptomatic vasospasm, hydrocephalus or rebleeding. All the patients had favourable outcome and were categorized as good recovery according to the Glasgow Outcome Scale. In comparison with the cases of aneurysmal SAH, especially in comparison with 48 cases with SAH caused by posterior circulation aneurysm, 43 cases could be easily distinguished on CT. The other 5 cases showed almost the same pattern of SAH on CT, but 4 cases could be differentiated by either the extension of SAH to the interhemispheric fissure or the presence of intraventricular hemorrhage. Only one case could not be differentiated on CT. Thus SAH located only around the brainstem differs from aneurysmal SAH in its clinical course, and in distribution and severity of bleeding on CT. This could be recognized as a new clinical entity and could be called benign SAH.

We have developed the protocol for selective cerebral perfusion (SCP) and pharmacological cerebral protection, and used it successfully in cases of aortic arch aneurysm. The subjects of the present study were 34 patients (28 males, 6 females) whose aortic arch aneurysm were surgically treated. Preoperative brain CT and brain scintigram showed high incidence of brain ischemia. However only 4 patients experienced a neurological episode. We conclude that our SCP technique and pharmacological cerebral protection are useful component to surgery of the aortic arch.

PURPOSE: To assess the hemodynamics and pathophysiology of stagnating arteries after removal of arteriovenous malformations (AVMs). SUBJECTS: 50 patients with supratentorial pial AVMs underwent pre- and postoperative angiographic studies. RESULTS: The following characteristics were found to correlate with stagnating arteries: 1) advanced patient age, 2) large AVM size, 3) markedly dilated feeders, 4) early postoperative angiograms, and 5) delayed restoration of feeding artery diameter. CONCLUSIONS: The rate of blood flow in the former feeding arteries, expressed as v x pi x r2 (v = mean velocity, r = vessel radius), suddenly decreases after removal of AVMs. When dilatation persists postoperatively in these arteries the flow velocity decreases and stagnation takes place. Delayed postoperative restoration of feeding artery diameter may be caused by a decrease of elasticity due to long-standing hemodynamic stresses, and by increased postoperative vascular resistance of these arteries.

We conducted a study to investigate whether an association exists among histologic findings, labeling index determined by the labeling index (LI) of proliferating cell nuclear antigen (PCNA) and recurrence in a population of 30 meningioma patients. All of 6 patients (invasive meningioma) with brain invasion had a PCNA LI in excess of 5%. Recurrence was found in 4 of these patients. In 24 patients who did not have brain invasion, PCNA LI was 4% or less and only 1 case had recurrence. Recurrence occurred in 3 of 25 patients who underwent macroscopic total resection and all of these 3 cases had brain invasion and a PCNA LI in excess of 5%. The findings of this study indicated the existence of a close correlation between peripheral invasiveness of meningioma and its biological behavior.

BALT magic catheter (PURSIL catheter) is a new catheter which is more flexible and plaint than the TRACKER-18 catheter because its mid-section and distal portion are made from polyurethane and silicon rather than polyethylene. Because the PURSIL catheter is flexible, it cannot be inserted with a guide wire, although it can be inserted into circulation during injection of contrast medium. Its inner diameter, 3.5mm, is smaller than that (5mm) of the TRACKER. There are few reports of embolization with the PURSIL catheter, and these describe only embolization using adhesive liquid embolus material. Embolization using small particles through the PURSIL catheter has never been reported. We report the catheterization using the PURSIL catheter of 26 arteries in 15 patients. The catheter was used for superselective angiography to clarify feeder and amytal tests in 5 patients with AVM, and embolization using PVA particles (150-250 microns) was performed in 1 patient with AVM, 3 patients with dural AVM, 4 cases with meningioma and 1 patient with vertebral aneurysm. Small PVA particles were easily injected without resistance through this catheter. In only one patient with dural AVM, was catheterization with this catheter not successful, and that was because the distal portion of the internal maxillar artery was extremely tortuous because of severe atherosclerosis. No complications associated with the use of this catheter were observed. We think that the greatest advantage of this catheter is the safety afforded by not using a guide wire. A disadvantage of this catheter is that, because of its small inner diameter, only small particles, or liquid embolus material can be injected through it.(ABSTRACT TRUNCATED AT 250 WORDS)

A 62-year-old woman was admitted complaining of clumsiness in both hands. On neurological examination, bilateral hand muscles were weak, both legs were spastic and hyperreflexic, all the extremities were hypoesthetic. Urological examination revealed detruser sphincter dyssynergia. Spinal CT scan demonstrated an iso density mass lesion in the cervical spinal cord, and it was markedly enhanced. On MRI, it was also markedly enhanced by Gd-DTPA. The operative finding was that an oval shaped tumor was buried in the spinal cord and was totally removed. Its histological diagnosis was neurofibroma. Intramedullary neurofibroma is rare and only 18 cases have been reported. In this case the tumor seemed to have arisen at the root entry zone and to have grown sub-pially.

Twenty-three patients (twenty males and three females) with acute cervical spinal cord injury were cared for within a defined protocol and followed for 14 to 589 days (mean. 133 days). We evaluated the relationship between neurological recovery and neurological examination, myelography (MLG), CT-myelography (CTM) on admission. All of them were admitted to Kitasato University Hospital within 24 hours after injury. Thirteen of the 23 patients had complete injury, and the others had incomplete injury.Four factors were found to be related to neurological recovery. They included: 1) complete injury; 2) areflexia; 3) cord swelling on CTM; and 4) complete block on MLG. Fourteen of 15 patients who had at most two of the four factors improved. But, no patients with three or four factors improved.These four factors have been recognized as indicators of bad neurological outcome. However, our result indicates that by our result, improvement of neurological function can be expected in patients affected by only one or two of these four factors. In other words these four factors have prognostic value for predicting the neurological outcome after acute cervical spinal cord injury.

Preoperative embolization for highly vascularized and large meningiomas is an indispensable technique for facilitating their surgical removal by decreasing blood loss during the operation. This is a report of 4 large and highly vascularized meningiomas in the skull base, on which embolization of feeders was performed preoperatively by PVA (Polyvinyl alcohol foam) particles (150-250 micron produced by INGENOR CO, Paris) and small strips of gelfoam (0.5 x 0.5 x 3-5mm). Under EEG monitoring, Isosorbide dinitrate was used for prevention and relief of vascular spasm. Lidocaine injection tests (Xylocaine 2%: 50mg mixed in equal volumes with Iopamiron 300) were performed for checking before embolization. In the intracranial portion, standard taper steerable guide wire was changed to seeker flexible soft-tip guide wire. In two cases, the meningioma was located in the medial part of the sphenoidal ridge. In the other two cases, one meningioma was in the lateral part of the sphenoidal ridge and the other was in the olfactory groove. In all 4 cases, we successfully performed embolization without complication. In one case, we had to perform embolization twice, because of revascularization detected by angiography 3 weeks after the first embolization. In this latter case, we had performed central embolization only, by using PVA particles, having left feeder without occlusion (peripheral embolization) using gelfoam. The result suggested that it was also necessary to perform peripheral embolization especially if the tumor is fed by large tortuous and irregular abnormal vessels. Peripheral embolization may prevent PVA particles from washing out and causing progressive thrombosis by PVA particles.(ABSTRACT TRUNCATED AT 250 WORDS)

Twenty-four patients with aneurysm of Valsalva sinus were surgically repaired over a 23 year period (1965-1988). These patients were ranged 2 to 54 years of age and eleven of them were male. Rupture of aneurysm of Valsalva sinus was combined with aneurysm in 20 cases, ventricular septal defect in 12 cases and aortic regurgitation in 6 cases. At present, our routine operative procedure for ruptured aneurysm is direct closure of the defect with patch closure of aneurysm after resection of the aneurysm, but when the diameter of aneurysm is smaller than 7 mm, direct closure of the defect of the aneurysm was used. Only one patient after patch closure of ruptured sinus of Valsalva (Konno type I) required reoperation for penetration into left ventricle. This case might be avoided if patch was sutured to annulus of aortic valve. There were two operative death and one late death. The former died of cerebral infarction and low output syndrome, the latter died of sepsis. The mean follow-up period (+/- standard deviation) was 8.2 +/- 6.0 years. All patients that were followed were thirteen and found to be in New York Heart Association class I.

We have reported a case of cervical spontaneous hematomyelia caused by cavernous hemangioma. A 47-year-old woman experienced a sudden onset of pain in the neck on 5 December 1979. One week after the onset she began to have tetraparesis. There was a rapidly increasing weakness of the extremities and she was referred to our department on 25 December 1979. At the time, the positive neurological findings were flaccid tetraplegia, bilateral loss of all sensory perception below the C4 level and urinary retention. Chest x-ray films demonstrated an elevation of right diaphragma. Roentgenograms of the cervical spine were normal. Emergency myelography via cisternal puncture revealed a central filling defect at the level of C3-C5. But there was no displacement of dentate ligament on lateral view, suggesting an intramedullary mass lesion. Laminectomy from C2 to Th1 and evacuation of the intramedullary blood clot at C3-C5 level were performed successfully. Microscopic examination of clots revealed cavernous hemangioma. The postoperative course was uneventful and the patient gradually improved in her motility. In the review of the literature including our case, vascular malformations are the commonest cause of spontaneous hematomyelia. They are found 12 out of 18 cases (Table 1). The symptoms of spontaneous hematomyelia are characterized by sudden onset of pain and rapid development of long tract sign in a previously asymptomatic individual. Operated cases are summarized in table 2. Good operative results are obtained 6 out 9 cases. We will emphasize that in a case of spontaneous hematomyelia with acute progression of transverse myelopathy, early diagnosis and operation are extremely important, and for this purpose, myelography is considered to be one of the most useful examinations.

The clinical study was undertaken on 24 poor risk patients out of 69 cases with hemorrhagic cerebral arteriovenous malformations, AVMs, and the surgical problems of poor risk patients with the lesions were discussed. The 24 cases, 35%, out of 69 hemorrhagic AVMs cases showed disturbances of consciousness of 3 digits (100-300) according to the Japan Coma Scale at the time of admission. All cases of these poor risk patients were observed less than 24 hours after the onset of the symptoms. Fifteen of these 24 cases showed brainstem signs including anisocoria and/or decerebrate rigidity and/or respiratory arrest. Eighty-three per cent of 24 poor risk patients had serious neurological defects as a result of the first hemorrhage. Therefore, it was impossible to prevent serious state from occurring in poor risk patients. Of the 69 cases with hemorrhagic AVMs, 56 cases were operated upon. Although 90% out of 38 good risk patients whose level of consciousness was 0 to 30 according to the Japan Coma Scale showed good recovery, only 44% of 18 poor risk patients recovered well. It could not be said that the surgical treatment gave satisfactory results for the poor risk patients when compared with the surgical results of the good risk patients. In respect to the location of AVMs, all three poor risk patients with AVMs in the corpus callosum and the ventricles showed good recovery, whereas of the poor risk patients with AVMs in the cerebrum or the cerebellum, only 4 out of 9 cases (44%) and 1 out of 6 cases (17%) showed good recovery respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

1. The antero-posterior diameter (APD-Fig. 1A) of the cervical spinal canals in 38 cases of symptomatic ossification of the posterior longitudinal ligament (OPLL) and 29 cases of asymptomatic OPLL was measured for each vertebra, and the thecoperiosteal diameter (TPD-Fig. 1B) of the cervical spinal canals in the same cases was measured. 2. The APD in the cases of symptomatic OPLL was found to be significantly smaller than those of asymptomatic OPLL. 3. The TPD in symptomatic OPLL was also found to be more significantly smaller than those of asymptomatic OPLL. Measurements of 9 mm or less were considered liable to be associated with cord compression. 4. The growing rate of the ossification was calculated in 13 cases of symptomatic OPLL which we have followed up radiologically for more than 2 years. The growing rate varied considerably from case to case. The average growing rate per one year was 4.07 mm in axial length and 0.67 mm in thickness on antero- posterior direction. 5. The incidence of OPLL was examined.

To understand the early stage of subdural neomembrane (SN) formation, we examined 23 outer SNs and two inner SNs of chronic subdural hematomas in surgical specimens. Ultrastructurally, the cellular component of the outer SN was fibroblasts, myofibroblasts, smooth-muscle cells (in four cases), blood vessels and blood-born cells. Dural border cells were observed only in limited areas. Namely, the outer SN is a simple granulation tissue which originates from multiple sources of mesenchymal cells in dura mater, and dural border cells are only one of constituent sources for SN formation. The inner SN was simply composed of slender spindle cells which were mostly fibroblasts and some were recognized as dural border cells. Our results showed that the subdural hematoma is actually an "intra" dural hematoma which is formed within the split dural border cell layer. The dura mater with rich vascular supply forms thick granulation tissue, that is outer SN and a few dural border cells on the underlying arachnoid membrane form thin fibrous inner SN.

The relationship between the postoperative ICP and the size of hematoma on CT scan and the time of operation was studied to evaluate their influence on the therapeutic results in the severe cases with hypertensive intracerebral hematoma. Twenty one patients of putaminal hemorrhage with severe neurological deficit (semicoma) were studied. ICP was monitored continuously by the Subdural balloon method after craniotomy to remove the hematoma. The relationship between the postoperative ICP level (High ICP: above 40 mmHg, Moderate ICP: 40-20 mmHg, Low ICP: below 20 mmHg), the size of hematoma estimated from CTscan (Large: more than 80 ml, Medium: less than 80 ml), the time from onset to removing hematoma and the therapeutic results were evaluated. The outcome six months after onset was determined according to the Glasgow Outcome Scale. Of 6 cases with Medium hematoma operated on within 8 hours, Low ICP was found in 5 cases (83%) and Moderate ICP was in one case (17%). Of 6 cases with Medium hematoma operated on after 8 hours, High and Moderate ICP were found in 3 cases (50%), respectively. In the cases with Large hematoma, Low ICP was not observed, but High ICP was found in 4 of 7 cases operated on within 8 hours (57.1%) and the other three indicated Moderate ICP (42.9%). High ICP was found in two cases with Large hematoma operated on after 8 hours (100%). The outcome of High ICP cases was severe disability in 4 cases, vegetative state in one and dead in 4, and that of Moderate ICP cases was moderate disability in 3 cases and severe disability in 4.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors reported three cases, whose vertebral arteries had been injured by blunt trauma to the neck which was followed by cerebello-brainstem infarctions. Case 1: a 32-year-old man, who developed severe vertigo and nausea 7 days after a traffic accident. He showed neck pain and horizontal nystagmus on admission. Three days later, he became drowsy. CT scan of the head demonstrated right-side cerebellar infarction, and the angiography revealed an occlusion of the right vertebral artery at C4-5 level. After the removal of the right cerebellar hemisphere, he recovered neurologically and was discharged from the hospital, able to walk. Case 2: a 47-year-old man, who suddenly became comatose 6 hours after an accident. Plain CT demonstrated a highly dense basilar artery. Angiography revealed the occlusion of the left vertebral artery, and severe stenosis of the right vertebral artery. The basilar artery was not visualized. Anticoagulant therapy was started immediately. He survived, but he developed locked-in syndrome. Case 3: a 53-year-old man, who developed transient apnea after an injury. On admission, neurological examination showed horizontal nystagmus, weakness of his right upper limb, and sensory disturbance in the left side of the body. Neck traction was done for spinal C1 and C2 fractures. Twenty-one hours after the injury, he became comatose suddenly. The four-vessels angiography revealed the occlusion of both vertebral arteries. The basilar artery was visualized through the posterior communicating arteries. He died on the 6th day after the trauma.(ABSTRACT TRUNCATED AT 250 WORDS)

Osteochondroma is one of the most common benign bone tumors, but it is rare in the spine. A woman aged 54 was admitted for investigation of left nuchal pain with radiation to the occipital region for one and a half years duration. Physical and neurological examinations revealed no objective abnormalities. The cervical spine film showed the presence of a calcified mass in the left articulation between atlas and axis. Myelogram outlined a left sided filling defect at the level of a calcified mass. The tumor was totally removed using operating microscope technique through transcervical approach. This calcified mass was confirmed as the benign osteochondroma by histological examination. The patient became completely symptom-free after the operation.

It is difficult to diagnose angiographically occult vascular malformations. When conventional CT (plaincontrast enhancement) can not demonstrate the lesions, it was impossible to diagnose in the past. We developed a new technique which enabled us to diagnose them. Materials and methods; Seven cases of spontaneous intracerebral hemorrhage, in which no abnormality was detected by repeated magnified serial angiography with subtraction technique and prolonged injection technique, were examined. In each case, conventional CT (plainenhancement using 100 ml of 60% meglumine iothalamate) was performed first, which was immediately followed by the administration of 220 ml of 30% meglumine iothalamate for one hour. CT is taken at the end of the infusion. It, we call, is prolonged high dose delayed contrast CT: PHDD-CT. Total dose of iodine used in this technique was 59.22 gI (1.0 gI/kg body weight: BW). Results; Contrast enhancement effect of PHDD-CT was much better than that of conventional CT in all the cases. In three cases, the lesions were more clearly delineated in PHDD-CT. In four cases, only PHDD-CT could demonstrate the lesions. No side effect was observed. Comments; Several techniques for better enhancement have been reported, however they used large volume of contrast medium such as 1.5 or 2.0 gI/kg BW. Our technique can be performed with more security. Based on our good results, we recommend to use this PHDD-CT technique for the diagnosis of angiographically occult vascular malformations.

Although it is of great tragedy to lose motor and sensory function of the spinal cord by spinal cord injury, there is no effective measure for complete cord lesions. In the central gray of the spinal cord at the region of injury, hemorrhagic necrosis and edema advance causing secondary damage to the spinal cord in rather early stage after injury. It has not been proved whether to remove necrotic tissue in the central gray matter can be effective to prevent secondary damage of the spinal cord or not. Operative result of six patients with acute physiologically complete cervical spinal cord lesion who have been subjected to posterior longitudinal myelotomy and removal of hematoma and necrotic tissue of the central gray of the spinal cord were evaluated. All of them admitted to Kitasato University Hospital within 24 hours after injury. They were five males and one female aged twenty to fifty-three. All the patients showed complete block of contrast medium on myelography at the level of one to two segments above the neurologically estimated level or injury of the spine, indicating marked swelling of the spinal cord. Average duration from injury to operation was sixteen hours ranging from six to thirty nine. Posterior longitudinal myelotomy was performed by using microsurgical technique. Skull traction was performed by using Crutchfield tongs for six weeks in five and twelve weeks in one of the patients. On admission forty mg of dexamethasone was used as steroid therapy followed gradual reduction.(ABSTRACT TRUNCATED AT 250 WORDS)