Quantitative measurement of the basilar arterial flow in the dog-electromagnetic flow-meter study of the extra-and intracranial arterial occlusion (author's transl)]

Recent advances in microneurosurgery have markedly improved the result of surgical treatment of aneurysm and arteriovenous malformation in the posterior cranial fossa. However, more precise study on hemodynamics of the vertebro-basilar system may be necessary for further progress in treatment of the vascular lesions. From this point of view, the authors studied the basilar arterial flow of the dog by means of an electromagnetic flow-meter and the flow probe which was specially devised by the authors. (1) The ratio of absolute value of the mean basilar flow to the total brain weight was calculated, and the flow rate was expressed in ml/100 g brain/min. Mean value was 7.1 ml/100 g brain/min under normocapnea. (2) The effect of occlusion of the common carotid, of the external carotid, of the intracranial internal carotid, and of the extracranial internal carotid on the basilar flow was less remarkable in this order. (3) Under normocapnea, occlusion of the unilateral common carotid artery produced 115% increase in the basilar arterial flow. Bilateral common carotid occlusion resulted in 312% increase of the flow, demonstrating a remarkable ability of compensation of the basilar artery through the circle of Willis and leptomeningeal anastomoses. Under hypercapnea, unilateral common carotid occlusion was followed by 81% increase in the basillar flow. Occlusion of both common carotids caused 230% increase in the basilar flow. Percent increase in the basilar flow after unilateral or bilateral common carotid occlusion under normocapnea was significantly larger than under hypercapnea (p less than 0.05 and p less than 0.01 respectively). It may be supposed that under normacapnea the increased basilar flow following bilateral common carotid occlusion may compensate the decrease in total cerebral blood flow due to carotid occlusion. However, the compensatory rise in the basilar flow under hypercapnea may be not enough to supply the dilated vascular bed in the carotid and basilar territories. There might be even a risk of deficiency of blood supply in the territory of the basilar artery, if the vascular resistance in the carotid area could become less than that in the basilar. The significance of CO2 inhalation therapy for ischemic cerebral lesion was discussed. (4) After the both common carotid arteries were occluded, the basilar aretry was clamped temporarily. Following release of basilar occlusion, reactive hyperemia was observed in the basilar flow. Magnitude and duration of the reactive hyperemia increased progressively depending on duration of the basilar occlusion to some extent. The phenomenon may be best explained by a progressive accumulation of vasodilating metabolities in the ischemic area. (5) Unilateral vertebral occlusion caused 37% decrease in the basilar flow. Bilateral vertebral occlusion resulted in reverse of the basilar flow, averaging 61% of the original value in flow rate. (6) Occlusion of the unilateral subclavian artery produced "subclavian steal phenomenon"...     

Th1 dominance in HAM/TSP and the optico-spinal form of multiple sclerosis versus Th2 dominance in mite antigen-specific IgE myelitis

To clarify the Th1/Th2 balance in spinal cord inflammation, we used ELISA to measure the total and allergen-specific IgE in 69 patients with clinically definite multiple sclerosis (MS), including 24 patients with the optico-spinal form of MS, 45 with HAM/TSP, 30 HTLV-I carriers without HAM/TSP, 40 patients with acute myelitis, 43 with neurodegenerative disorders, and 42 healthy subjects, and flow cytometry to study the intracellular IFNgamma-positive versus IL-4-positive cell ratio (intracellular IFNgamma/IL-4 ratio) in peripheral blood CD4(+) T cells in 40 patients with MS, including 17 patients with the optico-spinal form of MS, 23 with HAM/TSP, 22 with acute myelitis, 23 with neurodegenerative disorders, and 36 healthy subjects. Patients with HAM/TSP showed a significantly higher intracellular IFNgamma/IL-4 ratio, lower IL-4(+)/IFN-gamma(-) cell percentages, lower total IgE level, and lower frequency of cedar pollen-specific IgE than did the controls. The patients with optico-spinal MS showed a significantly higher intracellular IFNgamma/IL-4 ratio and higher IL-4(-)/IFN-gamma(+) cell percentages than the controls even at remission or in the convalescence phase. In contrast, in the patients with acute myelitis, the total serum IgE level and the frequency of mite antigen-specific IgE were significantly elevated in comparison to the controls, while those having mite antigen-specific IgE myelitis showed a significantly lower IFNgamma/IL-4 ratio in the CD4(+) T cells in comparison to the controls. These findings suggest that the Th1 cell response is predominant in HAM/TSP and optico-spinal MS, whereas the Th2 cell response is predominant in mite antigen-specific IgE myelitis.     

Characteristics of epilepsy in severely mentally retarded individuals

In order to clarify the characteristics of epilepsy in patients with severe mentally retarded (SMR) subjects, we analyzed 52 SMR subjects with epilepsy from the institute for SMR subjects at Kikuchi National Hospital, Kumamoto, Japan. A total of 61.5% patients had uncontrolled seizures which were resistant to treatment. The most common combinations of seizure types in those not responding to conventional anticonvulsants were generalized tonic-clonic seizures (GTCS) with tonic seizure and GTCS with atypical absence. Their clinical features were characterized by spastic paralysis associated with a slower background electroencephalogram and abnormal computed tomography scans of the head, suggesting the involvement of cortical damage. These findings suggest that a large proportion of epilepsy in SMR subjects does not respond to treatment and that the severity of organic brain damage may therefore affect the natural course of epilepsy in such patients.     

Percutaneous endoscopic gastrostomy (PEG) for the management of dysphagia: experiences in the neurosurgical care unit

This report concerns percutaneous endoscopic gastrostomy (PEG) administered in the neurosurgical care unit to a patient with dysphasia. This reliable nutrition route has the major advantage of minimal surgical invasion and can be expected to become a standard nutritional method. Since patients with neurological disorders account for the majority of those who need PEG, neurosurgeons need to be aware of the importance of PEG.     

Effects of perioperative protease inhibitor on inflammatory cytokines and acute-phase proteins in patients with hepatic resection

AIM: The objective of this study was to examine the effects of perioperative administration of ulinastatin, or urinary trypsin inhibitor (UTI), on inflammatory cytokines and acute-phase proteins induced by inflammatory cytokines in patients who had undergone hepatic resection. METHOD: Twenty patients admitted to the hospital for hepatic resection were equally randomized to one of two groups: the UTI group, those who were administered perioperative UTI, and the control group. RESULTS: The UTI group had no adverse effects from using UTI. Production of serum interleukin-6 (IL-6) tended to be attenuated in the UTI group when compared with the control group. Moreover, the UTI group had significantly decreased positive acute-phase C-reactive protein (p < 0.05) and significantly increased negative acute-phase protein prealbumin and retinol-binding protein (p < 0.05). Serum IL-6 levels significantly correlated with serum C-reactive protein levels on postoperative day 1 (r = 0.70, p < 0.01). CONCLUSION: These results suggest that perioperative administration of UTI might deserve further assessment for use in modulating acute-phase responses without adverse effects in patients who have undergone hepatic resection.     

Seven-year survivor with malignant melanoma of the anus without radical surgery

We report a case of a long-term survivor with malignant melanoma of the anus who did not undergo radical surgery. A 71-year-old woman who presented with anal bleeding and anal tumor underwent an excisional biopsy in September 1985. The biopsy specimen was a lobulated, polypoid, pigmented mass 2 cm in diameter, that had been located on the anterior wall of the anus. A satellite nodule 7 mm in diameter was found on the left wall of the anus at the level of the dentate line. Both tumors were histologically diagnosed as malignant melanoma. The primary tumor was 6 mm thick. Melanoma cells were present microscopically at the cut end of the rectum. Because of her history of ischemic heart disease, the patient rejected our recommendation that she undergo radical surgery, and received 10 courses of carboplatin 20 mg intramuscularly and OK-432 10 K.E. (Klinische Einheit) intradermally every week. A single, pigmented metastatic inguinal lymph node developed and was excised in June 1987. A recurrent tumor was detected in the rectum in October 1992, so again we recommended radical surgery. The patient rejected radical surgery again, and received 12 courses of carboplatin 10 mg intramuscularly every 2 weeks. She died of disease at home in July 1993 after surviving for 7 years and 10 months. An autopsy was not performed. This case shows that local excision of the primary lesion may be appropriate to preserve the quality of life of patients with early-stage malignant melanoma of the anus.