Prediction of outcome of prolonged coma caused by brain damage

Thirty-one prolonged coma patients, who continued in a comatose state for at least 2 months, were classified electrophysiologically employing EEG, a compressed spectral array of continuous EEG frequency analysis, BSR, SEP and SSEP. The prognoses of long-term follow-up (at least 8 months) in these patients were compared with the results of such electrophysiological analysis and with the neurological gradings of the prolonged coma patients. In the continuous EEG frequency analysis, 22 cases were classified as having a changeable spectrogram, nine cases as having a slow monotonous spectrogram, and no cases as having a borderline spectrogram. We also classified the changeable spectrograms into the following three patterns: no desynchronization, slight desynchronization, and desynchronization. The nine cases with a slow monotonous spectrogram revealed severe damage of the brain stem and cerebral function with multimodality evoked potentials, and most of these cases could not survive without assisted respiration. The 22 cases with a changeable spectrogram had mild damage of the brain stem and cerebral function with multimodality evoked potentials, and these cases were identical with a persistent vegetative state. Three of the cases showed a changeable spectrogram that revealed a desynchronization pattern, normal BSR and normal N20 of SEP and SSEP, recovered spontaneously from the persistent vegetative state within 6 months after electrophysiological evaluation. We conclude that not only a neurological but also an electrophysiological classification is necessary to evaluate the brain function and prognosis of prolonged coma.     

Ultracytochemical investigation of calcium-activated adenosine triphosphatase (Ca++-ATPase) in chick tibia

The ultrastructural distribution of Ca++-ATPase in bone cells of growing chick tibia was investigated by a cytochemical method in order to gain insight into possible sites of calcium ion translocation. Both osteoclasts and osteoblasts showed a polar distribution of reaction product along the plasma membrane. In osteoclasts, enzymatic activity occurred along the portion of the plasma membrane facing the marrow but not along the ruffled border or clear zone. The reaction product in these cells was due solely to Ca++-ATPase action. In osteoblasts, the plasma membrane facing away from bone (apical and lateral membrane) was very intensely stained, whereas the basal membrane was unstained. The reaction product in these cells appeared to be the result of both Ca++-ATPase and Ca++,Mg++-ATPase. In osteocytes, no plasma membrane staining was detectable. Mitochondrial staining in all three types of cells was more sensitive to fixation than was the plasma membrane enzyme, suggesting that mitochondrial and plasma membrane Ca++-ATPases are chemically distinct, as biochemical studies have shown. In general, mitochondria in osteoclasts stained more intensely than those in osteoblasts or osteocytes. Mitochondrial and vesicular sites of activity may be related to intracellular calcium storage, whereas calcium ATPases of the plasma membrane are presumed to be involved in calcium efflux from the cells. Calcitonin treatment did not alter the enzymatic distribution or intensity in osteoclasts. The striking polar distribution of both osteoclast and osteoblast plasma-membrane activity suggests that directional calcium pumping by these cells may be of importance in bone-forming and bone-resorbing mechanisms.     

Congenital pseudarthrosis of the tibia: analysis of the histology and the <Emphasis Type="Italic">NF1</Emphasis> gene

Background Congenital pseudarthrosis of the tibia (CPT) is frequently, but not always, associated with neurofibromatosis type 1 (NF1). Double inactivation of the NF1 gene has been reported to be the pathogenesis of CPT in NF1 cases. Methods We analyzed the loss of heterozygosity (LOH) of the NF1 gene in cases of CPT with NF1 to examine whether double inactivation was seen in the case. In addition to morphological analysis, immunoexpression of differentiation markers was examined. Results and discussion The tibia tapered with the zone phenomenon from mature to immature bone with osteoblastic rimming, resembling osteofibrous dysplasia. Osteosclerotic bowed bone with a small number of osteoclasts suggested dysfunction of bone remodeling. Fibrous tissue at the site of pseudarthrosis was associated with the periosteum and demonstrated myofibroblastic differentiation accompanied by massive cartilage formation, suggesting some misdirection during the differentiation of periosteum to myofibroblasts or chondrocytes. LOH of the NF1 gene locus was not seen in fibrous tissue. This result suggests that CPT is not accompanied by double inactivation in every NF1 case.     

Clinical use of Ga-67 DFO-DAS-fibrinogen

The clinical usefulness of 67Ga-DFO-DAS-fibrinogen, a newly developed thrombus imaging agent, was evaluated. Fifteen cases were given 2 mCi of 67Ga-DFO-DAS-fibrinogen and images were obtained up to 96 hours after injection. Abnormal accumulation of 67Ga-DFO-DAS-fibrinogen was imaged in seven cases with either venous or arterial thrombi, and no side effects were noted. These results suggested that 67Ga-DFO-DAS-fibrinogen might be a promising agent for thrombus imaging.     

Anorectal pressure monitoring during surgery on sacral lipomeningocele. Case report

Intraoperative monitoring of anorectal pressure was used in a case of sacral lipomeningocele accompanied by congenital dermal sinus to protect the physiological function of the anorectal sphincters. This monitoring system consists of a manometric anorectal balloon and neural electrical stimulation. The system was able to differentiate functioning neural structures from surrounding tissues during the operation.     

Effect of portal infusion of hypertonic saline on neurons in the dorsal motor nucleus of the vagus in the rat

Effects of hepatoportal osmo-receptive (or sodium-receptive) afferents on neurons within the dorsal motor nucleus of the vagus (DMV) were investigated electrophysiologically in urethane-chloralose anesthetized rats. Responses of 56 spontaneously active neurons to antidromic stimulation of the ventral trunk of the subdiaphragmatic vagus were recorded in the left DMV. Among them, 35 neurons were inhibited by electrical stimulation of the hepatic branch of the vagus nerve (inhibitory neurons), except two neurons that were slightly excited. Effects of portal infusion of 3.6% NaCl were examined on 26 inhibitory neurons. Sixteen neurons increased their discharge rates and one neuron decreased its discharge rate in response to portal infusion of hypertonic saline. Thirty-five DMV neurons responded to electrical stimulation of the dorsal trunk of the subdiaphragmatic vagus were inhibited by electrical stimulation of the hepatic branch of the vagus. Four neurons were excited by this stimulation. Relatively smaller number of neurons (5 out of 22 inhibitory neurons) increased their discharge rates in response to portal infusion of hypertonic saline. In conclusion, the response of DMV neuron observed in this experiment was characterized by increasing the frequency of spike discharges in response to portal infusion of hypertonic saline. However, these neurons were inhibited by electrical stimulation of the hepatic branch of the vagus nerve. These results suggest that the hepatoportal osmoreceptive afferents may be conveyed to the DMV via inhibitory synapses.     

Management of unruptured intracranial aneurysm in Japan: a Markovian decision analysis with utility measurements based on the Glasgow Outcome Scale.

The purpose of this study was to analyze the management of individual patients with unruptured intracranial aneurysms (UN-ANs) using a decision-analytic approach. Transition probabilities among Glasgow Outcome Scale (GOS) categories were estimated from the published literature and data from patients who had been treated at Kitasato University Hospital. Utilities were obtained from 140 health providers based principally on the GOS. Baseline analysis for a healthy 40-year-old man with an anterior UN-AN less than 10 mm in diameter showed that the quality-adjusted life expectancies for preventive operation and follow-up were 15.34 and 14.66 years, respectively. For a follow-up strategy to be preferred, the annual rupture rate had to be as low as 0.9%. These results were sustained through extensive sensitivity analysis. The results support preventive operation for UN-ANs, and identify problems that can be clarified with a well-designed stratified clinical trial.     

Idiopathic mediastinal fibrosis: Report of a case

(Received for publication on Nov. 14, 1996; accepted on May 12, 1997)     

Cerebral type of Lewy body disease

A cerebral type of Lewy body disease (LBD) is proposed. Lewy body disease was split formerly into three types: brainstem type, transitional type and diffuse type. The diffuse type is now called diffuse Lewy body disease (DLBD). These three types are characterized pathologically by the presence of a large number of Lewy bodies in the CNS. In the brainstem type, Lewy bodies are numerous in the brainstem and diencephalon nuclei, and in DLBD, a vast number are present not only in these nuclei but also in the cerebral cortex and amygdala. In the cerebral type of LBD, as many Lewy bodies are found in the cerebral cortex and in the amygdala as there are in DLBD, but only rarely are they present in the brainstem and diencephalon nuclei. Thus, this type of LBD is different from other types in that it has no parkinson pathology. Therefore, parkinsonism fails to occur throughout the whole clinical course of this disease. The existence of a cerebral type of LBD suggests that Lewy bodies occur in the cerebral cortex earlier than in the brainstem nuclei and that cortical Lewy bodies appear even when the mesocortical dopaminergic system is intact. In addition, this might explain why dementia frequently precedes parkinsonism in DLBD.