Migraine and isolated recurrent vertigo of unknown cause

Chronic recurrent attacks of vertigo, not associated with any auditory or neurological symptoms, are a common reason for referral to our neurotology clinic. Even after an extensive neurotological evaluation, some cases remain undiagnosed. We prospectively evaluated 72 consecutive patients who presented to the clinic with isolated recurrent vertigo of unknown cause. All patients underwent diagnostic evaluation to exclude identifiable causes of isolated recurrent vertigo. We compared the prevalence of migraine, according to the International Headache Society (IHS) criteria, in the isolated recurrent vertigo group, with a sex- and age-matched control group of orthopedic patients. The prevalence of migraine according to IHS criteria was higher in the isolated recurrent vertigo group (61.1%) than in the control group (10%; p < 0.01). Only 16.7% of patients had an abnormal vestibular function test. The most common abnormal finding was a unilateral vestibular weakness to caloric stimulation. Our results suggest that migraine should be considered in the differential diagnosis of isolated recurrent vertigo of unknown cause.     

Hypothalamic growth hormone deficiency and supplementary GH therapy in two patients with mitochondrial myopathy,encephalopathy, lactic acidosis and stroke-like episodes

Two pediatric patients with mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes were diagnosed with growth hormone deficiency with the primary lesion identified as the growth hormone-releasing factor producing cells of the hypothalamus. Stimulation tests with insulin, levodopa and sleep did not overcome the deficient pattern of growth hormone secretion. By comparison, the growth hormone-releasing factor stimulation test generated a normal growth hormone response in these two patients. Growth hormone supplementary therapy was effective in terms of growth gain without adverse effects.     

Postintubation tracheal stenosis; problems associated with choice of management

We experienced a case with tracheal stenosis due to postintubation damage, or so-called cuff stenosis. A 50-year-old man who attempted suicide by pounding nails into his head and chest using carpenter's tools was treated by endotracheal intubation and immediately underwent emergency surgery in July 2000. The patient was placed on artificial ventilation with oral endotracheal intubation, and a tracheostomy was performed 4 days after the operation. After that, his respiration recovered and he was weaned from the respirator. He was discharged 22 days after surgery with no respiratory symptoms. Two days after discharge, he complained of wheezing and dyspnea. Medical examination revealed that the cervical trachea had a severe circumferential stenosis 2.5 cm from the second tracheal cartilage. On retrospective inspection, the region of stenosis was compatible with the cuff site of the endotracheal tube used for the emergency operation. At first we tried nonoperative treatment, considering his mental state. However, we found that surgical treatment was ultimately necessary. A 2.5 cm sleeve resection of the trachea (5 tracheal cartilage rings) was performed, followed by end-to-end suture using 21 stitches with 4-0 MEDIFIT C thread. Pathologically, the surgical specimen showed degeneration and necrosis of tracheal cartilage with excessive growth of granulation tissue. These findings revealed that the etiologic basis of the tracheal stenosis was attributed to pressure necrosis by the cuff. The postoperative course was uneventful. Sixteen months after the surgery, the granulation tissue had not recurred, and problematic stenosis was not visible in the trachea. In this report, we discussed a reasonable management of postintubation tracheal stenosis. Tracheoplasty has been proposed as the most reliable method for treating tracheal stenosis. However, the best treatment in each case is still somewhat controversial because various nonoperative treatment methods are recently available, including laser phototherapy, argon plasma coagulation, mechanical dilatation, stent replacement, and drug treatment. Therefore, it is very important to judge properly the absolute indication for surgical treatment. If granulations are removed successfully by the above-described nonoperative methods, attempts at repair lead only to regrowth of granulation tissue as long as there is necrotic tracheal cartilage. Thus, the determinant of treatment methods is whether postintubation damage extends to tracheal cartilage or not. For now, there is no accurate diagnostic study for viability of cartilage preoperatively. In the literature, symptoms due to airway stenosis occurred rapidly within one month in the case of patients with necrosis of tracheal cartilage. We concluded that the period between extubation and development of symptoms is very informative in the management of postintubation tracheal stenosis. Surgical approaches should be selected for a patient with a rapid and progressive course after extubation when the patient can tolerate it.     

A resected case of solitary fibrous tumor of the pleura

A 45-year-old female with solitary fibrous tumor (SFT) of the pleura was reported. Chest X-ray and CT scan on admission showed a large tumor in the right thoracic cavity. A preoperative needle biopsy was performed. The microscopic appearance of biopsied specimen revealed many spindle cells. And an immunohistochemical study was positive for CD 34 and negative for keratin, epithelial membrane antigen, alpha-smooth muscle actin, S-100 protein. So SFT was strongly suspected and an operation was performed. A tumor arised from the visceral pleura of right middle lobe and was pedunculated. The tumor was 13 x 10 x 7.5 cm in size. An immunohistochemical study of the tumor was positive for CD 34, and negative for SMA, ki-67. From these immunohistochemical stainings and microscopic findings, the tumor was diagnosed as SFT. An immunohistochemical study of the tumor seems to be very useful for the diagnosis of SFT.     

Monte Carlo calculation of depth doses for small field of CyberKnife

PURPOSE: A Monte Carlo (MC) model of CyberKnife was developed as a quality assurance tool. The percentage depth dose (%dd) was verified by using this model. MATERIALS AND METHODS: An MC model was developed with Electron Gamma Shower version 4 (EGS4) in two steps: (1) a model of the CyberKnife treatment head and (2) a model of the collimator and phantom. The bremsstrahlung spectrum was calculated using the first model, and this spectrum was then used to calculate %dds with the second model. The calculated %dds for a large field (60 mm diameter) and three small fields (30, 15, and 5 mm diameter) were compared with those measured with a diamond detector. RESULTS AND DISCUSSION: The MC-calculated and measured %dd-curves for the 60 mm diameter field were in excellent agreement (<1.85%), thus confirming the validity of the model. Discrepancies between the calculated and measured %dd-curves increased with decreasing field size, with considerable discrepancy (11.62%) for the 5 mm diameter field due to lateral electron disequilibrium. Accurate dose can be determined with MC even in small fields. CONCLUSION: The MC technique can provide reliable standard data for accurate dose delivery with high-technology radiotherapies using small beams.     

Muscle MRI findings of HTLV-1-associated myelopathy

We report here the muscle MRI findings in two patients with human T-cell lymphotropic virus type I-associated myelopathy (HAM). It is known that thigh muscles are vulnerable in HAM patients, but detailed information about the affected muscles has not been available. Muscle MRI findings of these patients showed that thigh muscles, especially adductor magnus, and semimembranosus muscles were severely affected, but lower leg muscles were comparatively preserved. In these affected muscles, neurogenic changes were observed by EMG. We concluded that muscle MRI is very useful to estimate the affected muscles in HAM patients.     

Serum soluble interleukin-2 receptor (IL-2R) and immunohistochemical staining of IL-2R/Tac antigen in colorectal cancer

Background: In the present study, we investigated the significance of serum soluble interleukin-2 receptor (IL-2R) as a tumor marker, and examined the existence and localization of cells positive for IL-2R/Tac antigen in colorectal cancer tissues and their regional lymph nodes. Methods: The study included 155 patients with colorectal cancer. Levels of serum soluble IL-2R were measured by an enzyme-linked immunosorbent assay. In the tissues obtained from 18 patients, immunohistochemical staining was performed, with the use of the avidin-biotin-peroxidase complex technique, in which mouse anti-human IL-2R antibody was used. Results: The preoperative levels of serum soluble IL-2R in patients with colorectal cancer were significantly higher than those of normal controls (P = 0.0065). The levels of serum soluble IL-2R in patients with metastatic lymph nodes were also significantly higher than the levels in those without metastatic lymph nodes (P = 0.0258). Concerning tumor markers, there were significant differences in serum soluble IL-2R levels between patients who were positive and those who were negative for carcinoembryonic antigen (CEA) and between these who were positive and those who were negative for immunosuppressive acidic protein (IAP). In the immunohistochemical staining of IL-2R, 16 of the 18 patients (88.8%) showed IL-2R-positive cells in the colorectal cancer tissues. In regard to the metastatic lymph nodes, all of 5 patients (100%) showed IL-2R-positive cells. On the other hand, IL-2R-positive cells were not recognized in normal colorectal tissues and non-metastatic lymph nodes. Conclusion: These results suggest that activated T lymphocytes infiltrating into cancer tissues to play an antitumor role may release a large amount of the α-chain of IL-2R, resulting in the high levels of serum soluble IL-2R in patients with colorectal cancer. Received: October 18, 2001 / Accepted: June 12, 2002 Acknowledgments This study was supported in part by a Grant-in Aid for Scientific Research (11671269) from the Japanese Ministry of Education, Science, and Culture. Correspondence to:S. Murakami     

A case of tacrolimus nephrotoxicity appearing in a second renal transplantation patient

Oka K, Moriyama T, Imai E, Kyo M, Toki K, Tanaka T, Hori M, Kokado Y, Okuyama A, Takahara S. A case of tacrolimus toxicity appearing in a second renal transplantation patient. Clin Transplantation 2001: 15 (Supplement 5): 30–34. ©Munksgaard, 2001
We experienced a case of a second renal trans- plantation patient. With the use of cyclosporin, he lost his first graft because of chronic rejection; with the use of tacrolimus, his second graft suffered from drug nephrotox- icity. On his second renal transplantation, his graft function deteriorated and required haemodialysis with the use of tacrolimus. Repeated biopsies did not reveal the typical characteristics of acute tacrolimus nephrotoxicity and acute rejection. His tacrolimus trough level was not high during the clinical course; however, by reducing tacrolimus dosage, his graft function eventually recovered to mild renal dys- function. This observation was helpful for clinical diagnosis of the functional toxicity of tacrolimus. The case is interest- ing in considering the functional toxicity of tacrolimus and the difference between tacrolimus and cyclosporin in terms of immunosuppressive and nephrotoxic actions.