Postoperative analgesia with epidural morphine after hip operations (author's transl)

80 patients undergoing hip surgery under lumbar epidural block have been studied (double blind) for postoperative analgesia. There were 4 groups, of 20 patients each, who received a single epidural injection of 0 mg, 2 mg or 4 mg morphine in 1 ml of saline added to 6 ml bupivacaine 0.5% or 4 mg morphine in 6 ml saline. In the morphine groups analgesia lasted between 37 and 50 hours. No neurological side-effects or severe respiratory depression have was observed; but a significant rise of paCO2 was found. Other side-effects were nausea/vomiting and the need for catheterisation in about 50% of patients. We conclude, that the indications for epidural analgesia with morphine have to be chosen carefully.     

Extracalvarial meningioma--report of a case (author's transl)

A case of extracalvarial meningioma was reported. 75-year-old man was admitted to our department on November 11, 1974 because of a slowly growing tumor in the right frontoparietal area. The tumor was ovoid and 15x13 cm in size, protruding 5 cm above the skin level, and covered by the normal scalp. Neurological and electroencephalographic examination were negative. Spinal tap showed an opening pressure of 90 mm of water and clear CSF with 62 mg/dl of protein content. Plain roentgenogram and laminagram of the skull revealed both osteolytic and osteoblastic change in the outer and inner table of the skull just beneath the tumor. A right external carotid angiography disclosed a homogeneous extracalvarial tumor stain supplied by the superficial temporal artery and draining into the superficial temporal vein. A right carotid angiogram showed a 1 cm thick avacular area. The segmentally occluded superior sagittal sinus was displaced inward together with bridging collateral channels. Radiologically these picture corresponded to "intracranial non-globoid shape or avascular meningioma" discussed by Huckman et al. The tumor was well-circumscribed, encapsulated and loosely adherent to the periosteum and the skull except for a small portion through which the tumor was communicated with its intracranial part. Histological examination revealed that it was a typical endotheliomatous meningioma. This case should be allocated to the transitional or intermediate type between Lopez II and III type. In the schematical presentation (Fig. 6) we tried to readjust the rather confusing concept and classification of the extracalvarial meningioma.     

Computerized tomography in head injuries (author's transl)

Computerized tomography permits the registration of minimal density differences of cerebral tissue. The information obtained by this method is comparable to gross neuropathology. Demonstration of intracranial bleeding and other posttraumatic complications does not present any serious problem. Most of all, it permits for the first time to demonstrate directly parenchymatous lesions of cerebral tissue after a head injury. The treatment nowadays can depend largely on the results gained by computerized tomography. So the care of the patient will be influenced largely by the demonstration of lesions affecting the survival of the patient.     

Spinal subdural abscess-report of a case (author's transl)

A successfully treated case with a spinal subdural abscess in the lumbar region is reported. The patient, a 58-year-old male, had been suffered from fever and pain in the back for 2 months prior to the visit to a hospital, where pus was obtained through a lumbar puncture. He was then admitted to the Neurosurgical Clinic, Gunma University Hospital on September 6, 1974. On admission, neurological examination revealed an alert patient with flaccid paraparesis, sensory disturbance in bilateral lower limbs and urinary retention. Stiffness of the neck and Lasègue's sign were observed. The body temperature was 38.7 degrees C, white blood cell count 18,900/mn3, and erythrocyte sedimentation rate 118 mn per hour. Pus was again obtained from the spinal canal through a lumbar puncture between the fourth and fifth lumbar vertebrae. Cerebrospinal fluid obtained by a cisternal puncture was colorless clear, and the cell count was 60 WBCs/mn3, protein 154 mg/dl, and glucose 90 mg/dl. Plain roentgenograms of the spine were normal. Myelography showed a block at the level of the first thoracic vertebra, being accompanied with irregular subarachnoid defects. A lumbar laminectomy was performed on September 12, and an abscess adhering to the cauda equina was totally extirpated from the subdural space. Smear of the pus contained Gram-positive bacilli, but the culture was negative. Postoperative course was uneventful, and the neurological deficits were gradually improved. Fifteen months later, the patient could walk with a stick. A review of the available literature, including the present report, lists 14 cases with spinal subdural abscesses which have been induced via hematogenous spread. The symptomotology, clinical diagnosis, treatment and prognosis are briefly discussed. It should be emphasized that early diagnosis and emergency treatment are of choice in order to obtain an excellent operative morbidity.     

Intracranial mycotic aneurysm--report of a case (author's transl)

A case of intracranial mycotic aneurysm has been reported. The case was a 26-year-old female and was admitted to our hospital on November 11, 1975. She was semicomatous and showed right hemiplegia. On auscultation systolic murmur radiating from the mitral area to the left axilla was found. Left carotid angiogram showed a saccular aneurysm 5 mm in diameter, arising from peripheral portion of the percentral cerebral artery and accompanied by intracerebral hematoma. Emergency craniotomy was performed. A thin subdural hematoma, coated with pus, was found and microabcesses were seen to be scattered in the nearby subarachnoid space. After aneurysmectomy and removal of intracranial hematoma, the patient improved without complications. On histological examination of the aneurysmal wall, moderate degree of neutrophilic infiltration was found. It was especially marked around the vasa vasorum. Heretofore only eight cases of intracranial mycotic aneurysm have been reported in the domestic literature.     

Mesodiencephalic level of severe head injuries (author's transl)

From the study of 65 severe traumatic comas, the authors describe the syndrome of mesodiencephalic dysfunction, because of its frequency and its particular clinical signs. This peculiar level of loss of consciousness is characterized by a coma without mimic and without awakening after painful stimulation, by a stereotyped motor pattern in extension, by a perseverance of the photomotor reflex, while fronto-orbicular and vertical oculo-vestibular reflexes are lacking. This level of deterioration appears to be a critical point in the natural history of comatose patients. If this level is not surpassed, the probability of early death due to evolutive neurological lesion is low (18%). One half of these patients have a good prognosis, more than 75% have an excellent recovery. This high probability of recovery is decreased by a half when the level of mesencephalic dysfunction is reached.