An Experimental Study on the Effect of Reperfusion on Changes of rCBF in Focal Cerebral Ischemia

Reperfusion into focal ischemia using a transorbital snare ligature was studied in 20 unanesthetized cats following middle cerebral artery(MCA) occlusion of 1 to 6 hours duration. Changes of a regional cerebral flow(rCBF) were investigated upon with a hydrogen clearance method in the center and periphery of the MCA territory, which were correlated with the size of infarct delineated by a 2% triphenyl tetrazolium chloride solution and with the occurrence of severe brain edema or hemorrhagic infarct. The results were as followings: 1) Post-ischemic hyperperfusion was usually found after 1 hour occlusion of MCA followed by 2 hours recirculation. Final rCBF, however, reached pre-occlusion value and little or no infarct was found. 2) In the 2 hours occlusion-reperfusion group, hypoperfusion after reopening of MCA was regularly found in both the center and the periphery of ischemia, which was well contrasted with hyperperfusion in the 1 hour occlusion group and was accompained by evident but mild infarcts. 3) After 4 and 6 hours occlusion, there was usually evident post-ischemic hyperperfusion soon followed by development of severe hypoperfusion and a higher grade of infarct and hemispheric swelling was found. 4) Final hypoperfusion after transient MCA occlusion was observed only after ischemic periods lasting 2 hours or more irrespective of preceding post-ischemic hyperperfusion and was only related to the duration of the occlusion and not to the degree of blood flow disturbance. 5) Spontaneous hyperemia during occlusion was found in 3 of the 5 cats used in each of the 4 and 6 hours occlusion groups, in which there was marked hyperperfusion after reopening of MCA followed by severe hypoperfusion and transtentorial herniation associated with resulting extensive hemorrhagic infarct and marked hemispheric swelling. 6) Hemorrhagic infarcts were found in one cat of the 4 hour-occlusing group and two of the 6 hour-occlusion group, all of whom showed early hyperemia before reperfusion predictable of such a detrimental result. 7) These data indicate that potential hazard for surgical early revascularization in the acute stage of ischemic stroke should be considered in case profound ischemia had already progressed for 4 hours or more and especially when hyperemia during the initial stage of severe ischemia is observed at the center and the periphery of the ischemic area expected.

A Case of Suprasellar Germinoma Extended to Frontal Lobe

A 19-year-old boy was admitted with complaints of headache and generalized seizure for 5 months. On physical examination, he had a moon-face, a farty breast, no sexual hair, and childish voice. Neurological examination showed no abnormality except slightly decreased visual acuity in the left eye. Lumbar CSF had total 194 leucocytes in a high power field, and among these 95% was lymphocyte. Marked sellar ballooning was seen in simple X-rays. Both carotid angiogram revealed bilateral A1 elevation as tent-like fashion, and subfrontal mass was suspected in lateral view. Transfrontal Conray ventriculography was done, and accidentally tumor cyst was punctured and dark pinkish blood was evacuated. Transcoronal ventriculography was again performed and we knew the cystic subfrontal midline mass. Tumor mass was nearly removed, and pathological report was germinoma. He was discharged and radiation theraphy was given. He is well for 7 months post-operatively.

A Case of Suprasellar Germinoma Extended to Frontal Lobe

A 19-year-old boy was admitted with complaints of headache and generalized seizure for 5 months. On physical examination, he had a moon-face, a farty breast, no sexual hair, and childish voice. Neurological examination showed no abnormality except slightly decreased visual acuity in the left eye. Lumbar CSF had total 194 leucocytes in a high power field, and among these 95% was lymphocyte. Marked sellar ballooning was seen in simple X-rays. Both carotid angiogram revealed bilateral A1 elevation as tent-like fashion, and subfrontal mass was suspected in lateral view. Transfrontal Conray ventriculography was done, and accidentally tumor cyst was punctured and dark pinkish blood was evacuated. Transcoronal ventriculography was again performed and we knew the cystic subfrontal midline mass. Tumor mass was nearly removed, and pathological report was germinoma. He was discharged and radiation theraphy was given. He is well for 7 months post-operatively.

A Case of Hutchinson Type Neuroblastoma

Metastasis of neuroblastoma into the central nervous system is well known, but, in fact, rare clinically. Recently we had experienced one such case, which was characterized by sudden onset of paraplegia and blindness and delayed appearance of radiologic findings. A 7 years old Korean boy was admitted to the pediatric ward of the Seoul National University Hospital on September 28, 1975 due to sudden onset of paraplegia. All physical, laboratory and simple thoracic spine X-ray findings were normal except for albuminocytologic dissociation in the C.S.F. Guillain-Barre syndrome was suspected and steroid therapy was recommended. On November 10, 1975, he was readmitted due to sudden loss of visual acuity bilaterally. At first all radiologic examinations revealed no clue to the lesion. After 4 months from the onset, there appeared typical pedicular destruction of the thoracic spine and confirmed it as neuroblastoma by surgery.

A Case of Dumb-bell Shaped Spinal Ganglioneuroblastoma

The ganglioneuroblastoma is a rare tumor originating from the sympathetic chain. Both cytologically and biologically it is intermediate between the highly malignant neuroblastoma and the benign gauglioneurinoma. The predilection site of neuroblastoma is adrenal medulla, but ganglioneuroblastoma and ganglioneurinoma are frequently located in the retroperitoneum and mediastinum. We have recently experienced the dumb-bell shaped ganglioneuroblastoma at L-2 and 3 level. A 2 year-old-girl was admitted to Seoul National University hospital on May-1975 with complaints of lumbar back pain and kyphosis for 6 months. She had normal motor and sphincter function. Neurological examination showed normal. Simple lumbar spine X-ray showed the widening of interpedicular distance and erosion of the pedicle at L-2 and L-3. On lateral view scalloping of posterior border of L-2 was found. Lumbar puncture and myelography were failed. Total laminectomy at L-2, L-3 was done. Dumb-bell shaped mass was seen half in the extradural intraspinal space and half in the extraspinal space with pedicle in the widened intervertebral foramen. The mass was adult thumb-tip sized, dark grayish tan color, nodular surfaced, and well encapsulated. The tissue diagnosis was ganglioneuroblastoma. Post-operatively urinary secretion of vanyl-mandelic acid level was normal limit.

Clinical Analysis of Intracerebral Hematoma

Seventy cases of intracerebral hematomas were analysed, forty-six of spontaneous origin and remainder of traumatic one, which had been experienced in Seoul National University Hospital between March, 1970 and June, 1975. The results were as follows: A. Among forth-six cases of spontaneous intracerebral hematomas, twenty-six cases(52%) were primary intracerebral hematomas, normotensive or hypertensive, seven aneurismal ruptures(15%), seven arteriovenous malformations(15%), two cerebral rete mirabilies, one tumor bleeding, one leukemia, one idiopathic thrombocytopenic and one due to other blood dyscrasia. 1. Among twenty-six cases of primary intracerebral hematomas, angiography was performed in all and fourteen cases were operated. The sites of hemorrhage were as follows: a. Putaminal hemorrhage:17 cases(65%)(two cases associated with intraventricular hematoma). b. Thalamic hemorrhage:5 cases(19%)(two cases associated with intraventricular hematoma). c. Subcortical hemorrhage:4 cases(16%). 2. Overall mortality among twenty-six cases was forty-six per cent;operative mortality was forty-three per cent, and non-operative, fifty per cent. 3. Age, mode of onset, level of consciousness at the time of surgery and the site of hematoma were all important factors for surgical result. Surgical intervention seemed to be most favorable in patients who had verbal communication with subcortical or localized putaminal hematoma. 4. Normotensive group was worse than hypertensive one with conservative treatment, but the former was more benefited than the latter with surgery. 5. Intracerebral hematomas due to aneurismal rupture, arteriovenous malformation and others were also influenced with above mentioned factors, but the nature of underlined disease was of prime importance. B. Among twenty-four operated cases of traumatic intracerebral hematomas: 1. Five cases(21%) showed classical lucid interval with variable duration from thirty minutes to forty-eight hours. 2. Temporal lobe was most frequently involved(63%). 3. Lateral blow was predominant than axial low, and contrecoup than coup lesion. 4. Overall mortality was twenty-nine percent. 5. Age, lucid interval, preoperative level of consciousness and associated cerebral contusion or subdural hematoma were important factors for prognosis, but the preoperative level of consciousness was of prime importance.

A Case of Posterior Migrating of Herniated Lumbar Nucleus Pulposus Over the Cauda Equina

Recently we had experienced a case of posterior migration of herniated lumbar nucleus pulposus over the cauda equina, simulating a cord tumor clinically and radiologically. But we could hardly find any previous case report on it. A 35 years old man was admitted to our ward due to paraparesis on July 17, 1975. He had a history of back sprain five years ago with intermittently appearing mild lumbago. Two weeks prior to admission, there appeared severe left leg pain and soon resulted in paraparesis. Preoperative positive neurologic findings were paraparesis with left side foot drop, hypesthesia on the left L4, 5 and S1 dermatome and bilaterally decreased ankle and knee jerks. Myelogram revealed complete block at L2-3 with suspicious indentation filling defect at left L-5 interspace. C.S.F. protein value marked 738mg%. On operation, the dural sac was compressed by a posteriorly overriding mass on it at the L2-3 level. The mass was traced to its origin from the left side of the L2-3 interspace and into the ruptured posterior longitudinal ligament with a narrow pedicle. L4-5 interspace revealed a typically protruding type disc lesion. These were composed of degenerated nucleus pulposus on histological examination.

Familial Bilateral Acoustic Neuroma

The familial occurrence of bilateral acoustic neuroma has rarely been reported in the literatures, and its inheritance is known to be an autosomal dominant trait in association with or without von Recklinghausen's disease. Recently, we experienced an unusual case of bilateral acoustic neuroma, which was familially occurred in mother and her son. A 18-year-old Korean boy was referred to us due to bilateral hearing disturbance and staggering gait of one year duration. There were no stigmata of von Recklinghausen's disease. Neurological examination, simple skull films and vertebral angiograms revealed various evidences of bilateral cerebellopontine angle tumors. At operation, a hen egg-sized firm mass was subtotally removed at the left cerebellopontine angle region and a peanut-sized mass was totally removed at the right cerebellopontine angle region via suboccipital craniectomy. The histological diagnosis was neurofibroma. In family history, 13 years ago his mother was operated on C6-7 neurofibroma at her age of 28 years, and again operated on bilateral acoustic tumors 2 years later. The histological diagnosis was also neurofibroma.

Intrathecal Herniation of Lumbar Disc: Case Report

Rupture of the lumbar intervertebral disc into the dural sac is very rare. Total of 11 cases have been reported in the literatures. In Korea, one case of the intradural herniated disc of L4,5 interspace was reported at Seoul National University Hospital in 1972. Patients of the intradural herniated disc have usually a long history of recurrent low back pain and sudden exacerbation of symptoms with radiating pain on both lower extremities precipitated by minor trauma. A 47 years old female was admitted to Seoul National University Hospital complaining of wevere low back pain and radiating gluteal pain on both sides. She had had intermittent lumbago of 25 years' duration. Eight months prior to admission, radiating gluteal pain on both sides developed in addition to the aggravation of the lumbago due to minor back trauma. Physical and neurological examination showed local protrusion and the tenderness of the L3, L4 spinous process area, the hyperalgesia on the right L3, L4, and L5 dermatomes, no saddle anesthesia, normal dorsiflexion of both ankles and great toes, slight decrease of the right knee jerk and bilateral absence of the ankle jerk, and no sphincter dysfunction. Myelogram showed complete block at t he L3-4 interspace level. Total laminectomy of the L3 and L4 was done. When the dura was opened, a solid round mass of a thumb-tip size was seen occupying the whole dural sac, compressing the nerve roots. The mass was a herniated disc from L3-4 interspace that had ruptured through central part of the posterior longitudinal ligament and ventral dural wall. Protruded intradural mass was removed en masse after incision of the overlying arachnoid membrance and the remaining L3-4 interspace disc material was removed in pieces extradurally. The mass was revealed as a degenerated nucleus pulposus on microscopic examination. The patient had an uneventful recovery with improvement of the neurological deficits.

A Case of Parasellar Myxochondrosarcoma

Cartilaginous tumors of the skull base are rare. The authors recently encountered a case of parasellar myxochondrosarcoma. The clinical and more important differential diagnosis of the tumors of skull base are presented. A 49 years old Korean housewife was admitted to the dept. of Neurosurgery, Seoul National University Hospital because of the progressive visual disturbance of 3 years' duration. She had had mild headaches for 7 years. On physical examination, left homonymous hemianopia was noted. She could only see the moving hand in front of her right eye. Left visual acuity was quite normal. Other cranial nerves were not involved. Plain skull x-rays showed multiple stippled irregular calcifications around the right parasellar area. There was no evidence of bony destruction on the axial view. Right carotid angiogram showed the opening of carotid siphon, elevation of the bifurcation point of ICA, nonvisualization of the right ACA, and the forward-upward displacement with the thinning of the right internal carotid artery by the compression of the parasellar mass. There was no tumor blush or abnormal vessels. At surgery, a huge white avascular mass in the parasellar region, compressing and enveloping the right optic nerve and internal carotid artery was subtotally removed. The tumor mass extended far posterior to the dorsum sellae. The exact site of the origin was difficult to identify. The histologic diagnosis was myxochondrosarcoma. She was recommended the radiation therapy and discharged without improvement of her visual field in 3 weeks postoperatively.

A Case of Parasellar Myxochondrosarcoma

Cartilaginous tumors of the skull base are rare. The authors recently encountered a case of parasellar myxochondrosarcoma. The clinical and more important differential diagnosis of the tumors of skull base are presented. A 49 years old Korean housewife was admitted to the dept. of Neurosurgery, Seoul National University Hospital because of the progressive visual disturbance of 3 years' duration. She had had mild headaches for 7 years. On physical examination, left homonymous hemianopia was noted. She could only see the moving hand in front of her right eye. Left visual acuity was quite normal. Other cranial nerves were not involved. Plain skull x-rays showed multiple stippled irregular calcifications around the right parasellar area. There was no evidence of bony destruction on the axial view. Right carotid angiogram showed the opening of carotid siphon, elevation of the bifurcation point of ICA, nonvisualization of the right ACA, and the forward-upward displacement with the thinning of the right internal carotid artery by the compression of the parasellar mass. There was no tumor blush or abnormal vessels. At surgery, a huge white avascular mass in the parasellar region, compressing and enveloping the right optic nerve and internal carotid artery was subtotally removed. The tumor mass extended far posterior to the dorsum sellae. The exact site of the origin was difficult to identify. The histologic diagnosis was myxochondrosarcoma. She was recommended the radiation therapy and discharged without improvement of her visual field in 3 weeks postoperatively.

Studies of the Findings o Fluorescein Retinoangiographic Pictures of Papilledema in the Brain Tumor

Fluorescein retinal angography has been used in order to make differential diagnosis between true papilledema and pseudopapilledema, and to make early confirmation of the incipient papilledema. After injection of 5 cc of 10% fluorescein sodium into antecubital vein, the fluorescein retinal angiographic findings of 6 normal adults and 17 papilledematous patients of the brain tumor were obtained by Zeiss fundus camera(exciter filter:Kodak Wratten 47 A, barrier filter:Schott GG 14). 1. The characteristic findings of papilledema in the disc are: a. Leakage of fluorescein from capillaries and persistence of the fluorescence till late stage. b. Capillary dilatation. c. Microaneurysm. 2. The massive leakage of the fluorescen is seen in the patients of the 3 rd ventricular or posterior fossa tumors. 3. The decreased visual acuity is prominent in the patients showing marked capillary dilatation and microaneurysm.

A Case of Pituitary Apoplexy

A 46 years old woman was admitted to the department of Neurosurgery, Seoul National University, complaining of a sudden severe headaches and vomiting 7 days before admission. Three days later her vision became poor in the left eye and totally blind on the day of admission. She had amenorrhea for 15 years. On neurological examination, she was somewhat lethargic but fully conscious. Both optic discs were normal. Left pupil was dilated, fixed and totally ophthalmoplegic. Because of poor cooperation the visual field examination was not performed. Tongue protrusion was deviated to the right side. Cerebrospinal fluid was bloody. Skull X-rays showed a large pituitary fossa with erosion of the left anterior clinoid process and dorsum sellae. Left carotid anyiogram showed a finding of suprasellar extension of the intrasella mass. Retrograde brachial angiogram showed remarkable posterior displacement of the distal portion of the basilar artery. Left subfrontal approach was done and found a huge suprasellar mass compressing the left optic nerve. The tumor was aspirated and blood clot was obtained. The capsule was incised and content with hematoma was evacuated. Histologic examination showed complete blood clot with no recognizable neoplasm. Post-operatively, her left eyeball began to move and she was able to see some objects in close distance few hours after surgery.