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複雑部分発作重積 (Complex Partial Status Epilepticus, CPSE) は, 従来考えられていたほど稀ではないものの未だ報告は少ない。われわれは, 過去1年間の当院てんかん病棟入院患者のうちCPSEを繰返す4症例 (連続型2例, サイクル型2例) を経験した。連続型の1例は周期性の亜昏迷状態を, 他の1例は全身けいれん後のもうろう状態を繰返し, それぞれ非てんかん性の亜昏迷, 発作後もうろう状態と診断されていた。しかし両者とも前頭部優位のてんかん発作波の連続的な出現, ジアゼパムの静注による発作波の抑制が確認され, 前頭葉起源の連続型CPSEと診断した。特にもうろう状態を呈した症例は, てんかん発作波の消失後にもうろう状態が残るため, 早期の脳波検査が診断上重要だった。サイクル型の2症例は側頭葉てんかんで, 無反応相と部分的反応相が交互に頻回に繰返し, 脳波変化もそれに対応した。連続型CPSEの中に診断困難な症例が存することを強調したい。

Some gliomas are not noticeably enhanced on initial computer tomography (CT) scans. Such low-density non-enhancing gliomas have a relatively long period between onset and surgery ranging from 5 to 25 months. The mechanism causing the low density over a certain period of time in the sequential CT findings was retrospectively investigated. Characteristic histological findings associated with such low-density areas were microcystic formation, necrosis, intratumoral edema, infiltrative growth, and absence of capillary proliferation. Proliferation of capillary vessels is characteristic of CT enhancement.

A 50-year-old female was admitted because of nausea, vomiting, and cerebellar ataxia. Computed tomography scan revealed an enhanced mass accompanied with a cyst in the right cerebellar hemisphere. The mass situated in the subcortical region was removed. Histologically, highly vasculated tumor cells lined the cavities. Postoperative radio and chemotherapy were administered and the clinical symptoms improved gradually. Two months later, the patient complained of dyspnea. Chest X-ray on second admission demonstrated cardiomegaly. Hemorrhagic pericardial effusion amounting to 1000 ml was aspirated by pericardial puncture. Papillary clusters of tumor cells were demonstrated in the pericardial effusion. The patient died of cardiac failure. At necropsy solid tumors were located in the heart, lung, left inguinal region, and cerebellum. Histological diagnosis was mesothelioma arising from the heart. Primary pericardial mesotheliomas are rare; approximately 106 cases have been reported. Pericardial mesothelioma frequently spreads to the adjacent pleura and mediastinum, but distant metastases are extremely rare because patients with pericardial mesothelioma tend to die early due to cardiac failure or cardiac tamponade.

The clinical status of patients with glioma is influenced by 1) the histological malignancy of the tumor, 2) the tumor volume, 3) secondary status such as brain edema or intracranial hypertension due to the tumor, and 4) the host immunity. Due to some improvement in at least 2) and 3) by the initial treatment, most low grade glioma cases pass through a clinically silent postsurgical period. However, at a certain point, transition to a high grade tumor malignant transformation may occur with exacerbation of the symptoms. Twenty-two cases of histologically established low grade glioma experienced over the past 7 years, in which immunological status was evaluated, were analyzed. Nine cases (41%) showed malignant transformation. Characteristic pictures of the clinical symptoms, computed tomography (CT) scan findings, immunological status, and morphological findings (mainly immunohistochemical examination) in nine cases were delineated. The findings at the time of exacerbation of the symptoms were as follows. In all cases CT scan demonstrated the change in the main lesion from low density to mixed density and were compatible with a high grade glioma. Reduction in host immunity was verified. Morphological increase in the tumor volume, increase in histological malignancy and deterioration in the secondary status due to the tumor were confirmed. Necrosis of the tumor cells as well as increase in giant cells and gemistocytes were observed. Immunohistochemical analysis revealed a decrease and irregularity in glial fibrillary acidic protein positive cells and positive processes as well as increase in vimentin intensity. These findings demonstrate change in the biological characteristics of the tumor. It was not possible, however, to clarify the factors causing malignant transformation in low grade glioma.

Epidural EEG of 20 El mice is recorded under ketamine and xylazine anesthesia with epoxy coated silver balls as exploring electrodes. A stainless steel needle is placed subcutaneously near the nose as a reference electrode. Reproducibility of recording is remarkable. Multiple spike complex synchronizing on both frontal lobes is observed in 8 mice. Among them, small spikes preceding the multiple spike complex are also observed on the left frontal lead in 7 mice and on the right in 1 mouse. These spikes do not spread to occipital recordings. The discriminative ability of the recording is due to the coated electrode commonly employed with much larger animals and to suitable placement of the reference electrode. This simple and well known method permits the analysis of not yet satisfactorily explored the EEG of El mouse.

Alkaline phosphatase (ALPase) and Mg2+-activated ATPase (Mg2+-ATPase) activities were demonstrated in human brain tumors by light and electron microscopy. Four cases of glioma, i.e., two cases of astrocytoma, grade II, and two cases of glioblastoma, were used as materials. At the light microscopic level, Mg2+-ATPase activity was observed in the capillary wall and glial cells of both astrocytoma and glioblastoma. ALPase activity was restricted to the capillary wall. Its activity was stronger in glioblastoma than in astrocytoma. By electron microscopy, in astrocytoma, reaction product representing Mg2+-ATPase activity was distributed in the plasma membranes of endothelial cells and pericytes. Activity was primarily localized at the abluminal surface of endothelial cells and the surface of pericytes facing endothelium. The plasma membrane of glial cells was also positive. ALPase activity revealed essentially the same distribution pattern in blood vessels as above. In glioblastoma, on the other hand, activities of both phosphatases were markedly positive on the luminal surface of the plasma membrane of endothelial cells. They were much stronger than those along the abluminal endothelial surface. Phosphatase activities in brain tumor appear to change in localization pattern in association with glioma malignancy. This might reflect a functional aspect of changes in blood-brain barrier in glioma.

Morphological features of the autopsied specimens of 15 adult patients with supratentorial gliomas were analysed and the characteristics of recurrence of gliomas were searched for. The correlation between the computed tomography (CT) findings before death and the microscopic findings of a whole mount section of the brain was also analysed. The cases consisted of 2 grade II, 7 grade III and 6 grade IV astrocytomas. The characteristic CT findings before death were regrowth of the tumor mass or the occurrence of a new enhanced lesion in 14 out of 15 patients. The enhanced lesion showing regrowth of the tumor was located in the same site as the previous tumor mass. The new enhanced lesion, resulting in a trans or subependymal tumor spread, was seen in the ventricular wall, and this was a characteristic feature of the recurrence of gliomas. In morphological analysis, tumor regrowth and recurrent tumor cell infiltration into the brain parenchyma occurred in several patterns. One was the extending mode caused by regrowth of the residual tumor in spite of adjuvant therapy. CT scan correctly showed such tumor recurrence as an enhanced lesion, especially as a ring or nodular enhancement. In the second pattern, a spread of tumor cells occurred along the interfiber spaces to the brain stem, or to the contralateral cerebral hemisphere through the corpus callosum. CT scan could hardly show such a type of tumor cell infiltration. The third mode of tumor propagation was cerebrospinal fluid seeding, with intraventricular or subarachnoid tumor growth. The CT scan examined before death could display the tumor invasion of the intraventricular seeding in 3 out of 8 patients. Histologically, reinvasion of the tumor cells from the subarachnoid space to the brain parenchyma was along the Virchow-Robin spaces of penetrating blood vessels. If tumor regrowth was accompanied by angiogenesis, CT scan could show the recurrence as an enhanced lesion. Marked angiogenesis occurred in the margin of the residual tumor with central necrosis due to adjuvant therapy.

✓ In an effort to express the grades of mild disturbance of consciousness (MDOC), or clouding of consciousness, 25 items were selected for application in clinical examination. Factor analysis of the 25 items revealed that MDOC has a two-factor structure; namely, the performance factor (F1) and the verbal factor (F2). This structure was maintained in the sequential examinations. Guttman's scale analysis showed that the scale using the 25 items may be considered to approximate a unidimensional scale. By item selection according to communality, the 25 items could be reduced to 12 items without losing the two-factor structure or the usefulness and reliability of the examination. The principal component analysis (PCA) score, the F1 score, and the F2 score, calculated from the 12 items, were found to be good scales to describe an overall picture and characteristics of the F1 and the F2 of MDOC, respectively. Furthermore, by means of the characteristic curve (ogive) method, it was revealed that MDOC consisted of four clusters of items, the F2 factor (mild), F1 factor (mild), F2 factor (moderate), and F1 factor (moderate), according to the MDOC severity, so that a simpler scale composed of a representative item from each cluster could be constructed which exhibited a high correlation coefficient with the original PCA score.

Since 1977, 19 cases of malignant glioma (13 glioblastomas, 6 anaplastic astrocytomas) have been operated on with a CO2 laser. The ages of the patients varied from 11 to 73, with an average of 47. A total of 31 operations were performed in these 19 cases. The infiltration of the tumors was analyzed using the Daumas-Duport 3-D configuration classification of gliomas. Then, based on the analysis, the usefulness of the laser for each type of tumor was evaluated. Even in the Type I-D group (malignant glioma periphery showing either no or very limited infiltration), two of the three cases demonstrated recurrence within one year and nine months, respectively. In the Type II-D group (infiltrating glioma beyond the tumor tissue proper), the average survival term of nine of the 11 cases was 13 months after laser surgery. Independent of the 3-D configuration, tumors infiltrating beyond the basal ganglia or the opposite hemisphere via the corpus callosum cannot be totally removed, even with a laser. Thus, the recurrence of malignant glioma cannot be suppressed solely by laser surgery. However, by using a CO2 laser for malignant glioma, hemostasis can be sufficiently controlled and the tumor can be removed as much as possible in a short time without exerting a mechanical effect on the surrounding normal brain tissue.

✓ An implantable device for measurement of cerebrospinal fluid (CSF) flow in a ventriculoperitoneal shunt tube has been developed. The unit is energized by an extracorporeal high-frequency generator (200 KHz), and electrolysis creates bubbles in the shunt tube. Velocity of bubble flow is detected by a pair of ultrasonic Doppler probes placed a certain distance apart on the skin surface and in parallel with the implanted tube. The CSF flow rate is calculated taking into account velocity and tube diameter, and is expressed in ml/min. The unit consists of a coil with a capacitor, a silicon diode to rectify the high frequency, and a Zener diode to regulate maximum output voltage of 20 V. The output is fed to a pair of platinum electrodes placed inside the unit's tunnel through which the CSF flows. These components are molded in epoxy resin and coated with medical-grade silicone rubber. In animal experiments, CSF flow rates ranging from 0.033 to 1.0 ml/min could be measured by this flowmeter. Clinically, CSF flow has been measured to date in several cases. In two cases of communicating hydrocephalus occurring after the onset of cerebrovascular disease, and in which the CSF flow was continuously monitored for 24 hours, the flow rate ranged between 0.05 and 0.78 ml/min. The CSF flow rate fluctuates in a 24-hour period, increasing in the morning, especially between 12 midnight and 6 a.m., which suggests a circadian rhythm.

Morphological features and microscopic characteristics of the autopsied specimens of 14 adult cadavers with supratentorial recurrent gliomas were studied. One of the specific findings in the morphological change of the tumor cells was giant cell formation. These giant cells were subdivided into 3 types: 1) monstrous cell, 2) giant cell, and 3) gemistocytic cell. 1) Monstrous cells were found in 12 cases, 4 grade 3 astrocytomas and 8 glioblastomas out of 14 recurrent gliomas. These cells were defined as those larger than 150μm in diameter and having bizarre, irregular and hyperchromatic multinuclei. The glial fibrillary acidic protein (GFAP) stain of monstrous cells was negative. These cells were scattered in the periphery of the tumor or necrosis. 2) Giant cells were demonstrated in 3 glioblastoma cases. They were 100-150μm in diameter and had single or multiple nuclei. These cells were scattered in the periphery of both the tumor and necrosis, and contributed major cells of the tumor in two cases. The GFAP stain was negative in two cases and positive in one. 3) Gemistocytic cells were noted in 8 cases, 5 grade 3 astrocytomas and 3 glioblastomas, and were about 100μm in diameter. They had a single distinct nucleus. The distribution of the cells was in the marginal zone of the tumor or necrosis, or grouped around vessels in the tumor. The GFAP stain was positive. These results suggest that the specific cells indicated herein may be degenerative changes of the tumor cells exposed while withstanding such adverse conditions as hypoxia, irradiation, and chemotherapy.

9L tumor cells were transplanted into the left lobe of the brain in Fischer 344 rats. In one group, the brain tumor was grossly removed from the rats microsurgically on the 14th to 18th day after transplantation (operated group). These rats were decapitated 1, 6, 24, or 48 hr after surgery, having received 250 μc 3H-thymidine (3H-TdR) intraperitoneally 30 min before sacrifice. Both frontal lobes (operated left side and non-operated normal side) were removed and DNA was extracted using a modified Schmidt-Thannhauser method. 3H activity was then measured with a liquid scintillation spectrometer (LSC) to determine the 3H-TdR uptake into the DNA of the remaining tumor cells. A second group of rats which did not undergo tumor removal (non-operated group) received the same dosage of 3H-TdR 30 min before decapitation; the brain was removed postmortem, the tumor was then removed from the brain, and the same extraction procedures and uptake measurements were performed. For comparison of the two groups, the relative increased radioactivity (RIRA) in the brain was determined as a ratio of the counts per gram (cpg) in the tissue of the left lobe, from which tumor was removed, to the cpg in the normal right lobe. RIRA in the non-operated group was 5.7, indicating that the 3H-TdR uptake of tissue in the left lobe, which contained some remaining tumor cells, was 5.7 times higher than that in the normal lobe. In the operated group, RIRA was 1.5 and 1.7 respectively in the rats sacrificed 1 and 6 hr after surgery, which indicated that remaining tumor cells had virtually ceased to proliferate; however, in rats sacrificed 24 hr after surgery, RIRA was 4.9, which approached the same level as that in the non-operated group. In the rats sacrificed 48 hr after surgery, RIRA was as high as 9.5. These results showed that for at least 6 hr after surgery there was almost no proliferation, but by 24 hr after surgery, active division of the remaining tumor cells had resumed. To confirm both 3H-TdR perfusion in the tissue and tissue permeability, a third group consisting of operated rats received 3H-TdR and 14C-urea before being decapitated. Both frontal lobes were lyophilized and activities of the 3H and 14C were measured with LSC. During an observation time of up to 48 hr, there was no significant fluctuation in the level of available 3H-TdR in tissue or in the tissue permeability, as indicated by 14C-urea space.

Glioma often recurs after apparently successful treatment and clinical remission. The effect of the host's immunologic status in such cases is unknown. In this study, the authors attempted to answer the following questions: 1) Is there a relationship between immunity and the recurrence of glioma? 2) Is immunologic monitoring useful in predicting the recurrence of glioma? 3) Which immunologic monitoring system is the most reliable? The subjects were 17 patients with gliomas who were treated between 1980 and 1985 and had tumor recurrence after an interval of clinical remission. They were evaluated during and after remission by means of clinical signs, computed tomography, and immunologic testing, which included measurement of purified protein derivative (PPD), phytohemagglutinin (PHA), the blastogenic response of T-lymphocytes to PHA, the OKT4 and OKT8 lymphocyte subsets, and serum complement CH50. The patients were divided into two groups. Group 1 comprised five patients whose tumors showed malignant transformation from grade 2 to grade 3. Group 2 included patients whose tumors were of the same histologic grade initially and on recurrence. In Group 2, six tumors were grade 3 and six were grade 4. Lowered immunity at the time of recurrence was demonstrated by the following: 1) a negative change in PPD and/or the PHA skin reaction in 80% of Group 1 and 75% of Group 2 patients; 2) elevation of CH50 in 40% of Group 1 and 58% of Group 2 patients; 3) a change in the blastogenic response of T-lymphocytes to PHA in 40% of Group 1 and 25% of Group 2 patients; and 4) an decrease in OKT4/OKT8 cell ratio in 60% of Group 1 and 38% of Group 2 patients. These patients were immunologically competent during remission. The immunologic changes at the time of tumor recurrence were accompanied by clinical deterioration. However, tumor recurrence could not be predicted from the immunologic parameters studied. Thus, it appears that extension or recurrence of the gliomas was responsible for lowered immunity in these patients, rather than the opposite.

Three cases illustrating the moyamoya phenomenon and an aneurysm in the periphery of the lateral ventricle in angiograms are reported. The mechanism of occurrence of an aneurysm in the moyamoya phenomenon is discussed.

Neuromonitoring of brainstem auditory evoked potentials (BAEP), short-latency somatosensory evoked potentials (SSEP), compressed spectral arrays (CSA) and/or conventional EEG can provide useful information on neuronal dysfunction within the brainstem and cerebrum in severely brain-damaged patients with elevated intracranial pressure (ICP). This study was undertaken to delineate the evolution of neuronal dysfunction in terms of the relationships among neuromonitoring and neurological findings, ICP and cerebral perfusion pressure (CPP).

Patients are often encountered who do not require immediate surgery but for whom strict follow-up of intracranial pathophysiology is necessary for fear of an enlarging hematoma, the occurrence of a delayed hematoma, and the development of herniation. In such cases, the ideal procedure during the pre-surgery period is for intracranial pressure (ICP) monitoring, and neurological and CT follow-ups and so on to be performed in conjunction with medical treatment.

A 42-year-old female was admitted because of numbness on the right half of the body, motor weakness in the right upper extremity, and unconsciousness. The patient complained of an increase in appetite and gradual weight gain. A diagnosis of pituitary microadenoma with Cushing's disease had been made. Neurological examination revealed drowsiness, expressive aphasia, right hemiparesis, and neck stiffness. A plain craniogram showed a normal sella turcica. CT scans showed a left putaminal hemorrhage with marked midline shift to the right. On the 4th hospital day, after correction of subnormal serum electrolytes which had been worsened by the administration of steroid and hypertonic solutions, a craniotomy was performed to evacuate the hematoma and the patient's condition improved. Eight weeks after the craniotomy, a transsphenoidal pituitary adenomectomy was carried out. The adenoma (3 mm in diameter) was histologically confirmed to be a mucoid cell adenoma. Cases of hypertensive intracerebral hemorrhage associated with Cushing's disease have rarely been reported despite the common occurrence of systemic hypertension and vulnerability to bruising. In such cases, the intracerebral hematoma should be evacuated to prevent further deterioration of the subnormal serum electrolyte level caused by steroid and osmotherapy.

✓ Autonomic and somatomotor responses to electrical stimulation of the posterior hypothalamus are reported in 51 patients with pathologically aggressive behavior. The stimulated area causing rise in blood pressure, tachycardia, and maximal pupillary dilatation lies in the posteromedial hypothalamus, more than 1 mm and less than 5 mm lateral to the lateral wall of the third ventricle, occupying a triangle formed by the midpoint of the intercommissural line, the rostral end of the aqueduct, and the anterior border of the mammillary body. Electrical stimulation of this (ergotropic) triangle resulted in desynchronization of the electroencephalogram (EEG) with hippocampal theta waves, or diffuse irregular delta waves of high voltage. Cases with violent behavior showed higher plasma levels of non-esterified fatty acids (NEFA) in the fasting stage; these were markedly elevated by electrical stimulation of the ergotropic triangle. Points in the ergotropic triangle where signs of sympathetic discharge were most marked were electrocauterized bilaterally. This procedure produced marked calming effects (95% of the cases) during the follow-up period of more than 2 years. Postoperatively there was a tendency to a decrease in sympathicotonia or an increase in parasympathicotonia. The follow-up plasma level of NEFA was found to have decreased to approximately the normal value.