Transcranial Doppler CO2 Test as an Indicator of Cerebral Vasoreactivity and Prognosis in Patients with Regional CBF Alteration

The assessment of cerebral vasoreactivity provides information on the reserve capacity of cerebral circulation in patients with cerevrovascular disease. It also allows for the diagnosis of impending ischemia and control of the effect of initiated corrective measures. The authors had performed transcranial doppler(TCD) studies to measure the CO2 reactivity of the entire basal cerebral arteries in 30 cases of age-adjusted control group and 42cases of disease group and 42 cases of disease group between the 3rd and 7th day after insult. The disease group involved 14 cases of head injury, 10 cases of intraventricular hemorrhage, 10 cases of subarachnoid hemorrhage and 8 cases of hydrocephalus. All patients were examined by single photon emission computed tomography(SPECT) and results of the 2 groups were compared with respect to their CO2 reactivities. In the patient group, the mean blood flow velocity(MBFV), pusatility index(PI) and MI index(middle cerebral artery MBFV/internal cerebral artery MBFV) had not changed but the CO2 index was significantly lower than that in the same age group of normal control. The regions showing abnormal ROI(region of interest) on SPECT well corresponded with the regions showing decreased CO2 reactivity on TCD. Both the increase of MBFV and the decrease of Pl were noted in the cerebral arteries with decreased CO2 reactivity. This indicates that the very arterial walls were dilated. As for the relationships between the investigated variables, ROI increased as the clinical status worsen(r=-0.05, p=0.0008). The acute prognosis(prognosis after 3month of insult) had positive correlation with CO2 index(r=0.32, p=0.04) of clinical status, while on the other hand, its correlation with ROI index was negative(r=0.40, p=0.0094). Transcranial doppler CO2 test provides useful information for the understanding of hemodynamic status, prognosis and beneficial effects of specific therapy. It is concluded that CO2 index measured during the subacute stage of insult correlates well with the acute prognosis.

Tissue Plasminogen Activator in Choronic Subdural Hematoma & Its Relationship with CT Findings

No abstract available.

Post-Traumatic Cerebral Infarction

We report a series of 19 consecutive patients with post-traumatic cerebral infarction. Post-traumatic cerebral infarction(PTCI) was diagnosed by CT within 24 hours of admission in 6 cases and up to 14 days after admission in 13 cases of 1092 patients who required cranial CT for trauma during the period. The frequency, vaascular territories, cause, and mortality rate of post traumatic cerebral infarction were discussed.

Effect of Allopurinol on Brain Infarction Following Middle Cerebral Artery Occlusion in Rats

Of the many potential source of free radial generation, the enzyme xanthine oxidase has been shown to be important in ischemia in non-cerebral tissues. Oxygen-derived free radicals have been implicated in various pathological conditions including ischemia. Xanthine oxidase serve as a source of oxidizing agents such as superoxide radical and hydrogen peroxide. It is investigated that the effect of a specific xanthine oxidase inhibitor, allopurinol, on infarct size in a model of continuous partial cerebral ischemia in rats. Infarct volume was measured by triphenyl tetrazolium chloride staining of brains removed 24 hours after middle cerebral arterial occlusion. Cortical tissue was more effectively protected than basal tissue, especially in allopurinol pretreated group. On histological examinations, hemispheric swelling, PMN cell infiltration and endothelial damage were noted irrespective of allopurinol treatment. It was speculated that free radicals are important in infarction secondary to partial continuous cerebral ischemia and that xanthine oxidase may by the primary source of these radicals.

A Study of the Effects of Systemic Heparin and Intrathecal Urokinase on Experimental Cerebral Vasospasm

The author has investigated the protective effects of systemic Heparin and intrathecal Urokinase in the multi-hemorrhage canine model of severe chronic cerebral vasospasm. Each of 20 adult mongrel dogs was assigned to one of three experimental groups. All animals received a total of 12ml of fresh unheparinized autologous blood via three cisternal injections. Selective vertebral angiograms were obtained before and 8 days after the initial subarachnoid blood injection. Seven animals were treated by systemic Heparin for 7 days, the other seven were treated by intracisternal Urokinase for 3 days, and the remaining were not treated. Comparisons were based on the percentage of reduction in basilar artery diameter(% RBAD). The ultrastructural changes were studied by transmission electron microscopy(TEM). There was a mean reduction(+/-standard deviation) of 65+/-7% in control dogs, 53+/-5% in dogs with systemic Heparin(difference significant t-test, p<0.01), 37+/-6% in dogs with intrathecal Urokinase(difference signignificant, t-test, p<0.01). The preventive effects of intrathecal Urokinase was superior to systemic Heparin. There was a stroung trend toward reduction of medial necrosis in the basilar artery in dogs with intrathecal Urokinase(p<0.01), and with systemic Heparin(0.05

An Experimental Study of the Bilchemical Alterations in the Acute Focal Cerebral Ischemia:Energy Metabolism

It is the purpose of this experimental study to investigate the alterations of the amount of adenosine nucleotides and adenylate energy charge in the acute focal cerebral ischemia of cats utilizing high performance liquid chromatography and to make a comparative study of protective effects of recirculation and combined therapy with mannitol, steroid and barbiturate. Acute focal cerebral ischemia in cats was induced by occlusion of the left middle cerebral artery through the postorbital technique. The experimental animals were divided into four groups according to the duration of occlusion time. The experimental results are obtained as follows: 1) In 1, 3 and 5 hour-occlusion groups, amount of adenosine triphosphate and summation of adenosine nucleotides decreased significantly to 21.4%, 5% & 0%, 44.0%, 29.9% & 10.8% of the sham control, respectively. Also in these groups adenylate energy charge decreased significantly to 62.7%, 38.7% and 30.7% of the sham control, respectively. It was suggested that the longer duration of occlusion time was, the more amount of adenosine triphosphate, summation of adenosine nucleotides and adenylate energy charge decreased significantly. 2) In 1 and 3 hour-occlusion groups, 2 hour-recirculation increased significantly amount of adenosine triphosphate and summation of adenosine nucleotides to 37.4% & 29.4%, and 62.1% & 58.3% of the sham control, respectively. Also in these groups recirculation increased significantly adenylate energy charge to 70.7% and 65.3% of the sham control, respectively. Whereas there was a slight increase of adenylate energy charge after recirculation in 5 hour-occlusion group, but not significant. 3) In the groups of recirculation following 5 hour-occlusion, pretreatment of combination of mannitol and steroid, or mannitol, steroid and barbiturate increased significantly amount of adenosine triphosphate, summation of adenosine nucleotides, and adenylate energy charge to 57.2% or 66.1%, 80.9% or 83.5% and 82.7% or 84.0% of sham control, respectively.

Effect of Calcium Antagonist(Nicardipine) on CBF, CMRO2, and CMRG in Experimental Cerebral Vasopasm

The author investigated the cerebral circulatory and metabolic effects of systemic and intracisternal administration of nicardipine in a canine model of chronic cerebral vasospasm. Twenty-one dogs were assigned to one of three groups; control, intravenous nicardipine, and intracisternal nicardipine. All animals received a total of 12 ml of fresh unheparinized autologous blood via three cisternal injections. Sequential measurements of cerebral blood flow(CBF), cerebral metabolic rate of oxygen(CMRO2), and cerebral metabolic rate of glucose(CMRG) were chacked four times in nine days. Animals were sacrificed at Day 9 and amount of clot remained in brainstem and basal cistern was graded accordingly. Significant improvement of cerebral blood flow was noted in Day 6, Day 9 of intracisternal group and in Day 3, Day 6 of intravenous group(each, p<0.05) with slight better results seen in intracisthernal group. Results of sequential changes of CMRO2 and CMRG indicated possible role of nicardipine in protective effects on deleterious neuronal damage following ischemic changes after vasospasm, but definitive statements on this subject matter should be reserved until further study, espedially on morphologic examinations is carried on, Significantly less amount of clot remained in intracisthernal group may be due to effects of nicardipine in its inhibitory action on platelet aggregation, and/or stimulatory effect on prostacyclin production. These factors along with other possible factors should be speculated.

Effects of Intrathecal Baclofen on Spasticity

9 patients with spasticity of cerebral or spinal cord origin have been maintained for upto 2 months with intermittent bolus spinal intrathecal infusion of baclofen. Prior to treatment, all of patients had severe spastiuity in extremties & had frequent & extensive spontaneous spasms, all of which greatly interfered with their activities of daily living. Oral antispasmodic medications were ineffective. Within days of intrathecal baclofen infusion, the muscle tone was reduced remarkable & spasms were eliminated. The greatest benefit to the patients were improvement in activities of daily living & better sleep due to reduced spasms. Complications were not observed.

Experimential Brain Stem Compression

Patterns of brain-stem compression and secondary brain-stem evoked postentials were investigated to correlate with expanding mass volume and location in mass-induced supratentorial brain compression in cats in which the subjects were divided into four experimental group i.e., frontal, temporal, parietal, and occipital brain-compressed groups. Postmortem insepection of the brain-stem showed either unilateral or bilateral dorsal herniation of the brain in frontal and temporal brain-compressed groups and dorsolateral herniation in parietal and occipital brain-compressed groups, respectively. Microscopic examination revealed that the secondary brain-stem hemorrhages were mostly caused by venous bleeding secondary to venous congestion, the bleeding being more severe in occipital brain-compressed group. As the intracranial pressure was raised by expansion of a supratentorial balloon, the late components of the BSEP were suppressed first, followed by the suppression of the early components. In BSEP recording a significant change was observed in Vth wave with prolongation of latency and decrease in amplitude. This finding suggests that the midbrain is the most vulnerable to compression ischemia. In parietal group, the Vth wave started to be prolonged at 0.4ml of balloon expansion and totally disappeared at 1.8ml of expansion.

A Study of the Effect of Naloxone on the Lipid Peroxidation and the Fine Structure of the Myelin Sheath in the Injured Spinal Cord

Spinal Cord contusions in cats were produced experimentally by impact injuries to the surgically exposed cord at the second lumbar vertebral level. As a step in the investigation of the possible effect of spinal cord trauma on biochemical and ultrastructural changes in the injured cord, activities of lipid peroxidation were measured in the frozen-dried sample of the spinal cord and the fine structure of the myelinated nerve fiber in the white matter were observed before and after the cord injury. An increase of lipid peroxidation level was found as early as 30 minutes after the injury and the highest concentration was reached at 4 hours of injury. Fine structures of the myelinated nerve fibers were changed progressively with the lapse of time after the injury. By 1 hour after the contusion the myelinated nerve fibers showed moderately enlarged periaxonal space, attenuation and disarray of the myelin sheaths. By 4 hour after the contusion, there appeared disarray of the myelin sheaths, greatly enlarged periaxonal space and irregulary contoured axons. The effect of naloxone of the lipid peroxidation and fine ultrastructure of the myelinated nerve fibers were studied, and the results of this study suggested that naloxone have a beneficial effect on the change in lipid peroxidation and the preservation of the myelinated nerve fibers after injury.

Clinical Analysis of Ruptured Intracranial Aneurysms

The author analyzed 177 consecutive cases of saccular, ruptured intracranial aneurysms admitted to the Department of Neurosurgery in Korea University Hospital during the period from August 1983 to July 1987. the results of analysis were summarized as follows. 1) Mean age of the patients was 50.4 years. 2) Incidence of clinical vasospasm was 27.2%(46/177) and of rebleeding was 10.7%(19/177). 3) Surgery was done for patients which accounts for 57.6% of all patients. Functional recovery was noted in 84 of the these surgically treated patients(84.6%). 4) The prognostic factors are age, hypertension, size of aneurysm, site of aneurysm, preoperative neurological state, vasospasm, hydrocephalus, rebleeding, timing of operation, multiplicity. 5) The mean size of aneurysms was 6.9mm. The direction of aneurysms was variable, but most of them pointed in the direction of blood flow in afferent arteries.

Clinical Analysis of Ruptured Intracranial Aneurysms

The author analyzed 177 consecutive cases of saccular, ruptured intracranial aneurysms admitted to the Department of Neurosurgery in Korea University Hospital during the period from August 1983 to July 1987. the results of analysis were summarized as follows. 1) Mean age of the patients was 50.4 years. 2) Incidence of clinical vasospasm was 27.2%(46/177) and of rebleeding was 10.7%(19/177). 3) Surgery was done for patients which accounts for 57.6% of all patients. Functional recovery was noted in 84 of the these surgically treated patients(84.6%). 4) The prognostic factors are age, hypertension, size of aneurysm, site of aneurysm, preoperative neurological state, vasospasm, hydrocephalus, rebleeding, timing of operation, multiplicity. 5) The mean size of aneurysms was 6.9mm. The direction of aneurysms was variable, but most of them pointed in the direction of blood flow in afferent arteries.

A Case of Arteriovenous Malformation Harboring of Large Venous Aneurysm

A case of AVM(Arteriovenous Malformation) harboring a large venous aneurysm is presented. The AVM was located in right temporo-parietal area. The pathology revealed a AVM and large venous aneurysm which was attached to nidus and drained into petrosal sinus. The authors reviewed the pathology of AVM and venous aneurysm.

Evaluation of the Effect of Myelotomy on Experimental Acute Spinal Cord Injury with Spinal Evoked Potentials

Direct spinal epidural surface of spinal evoked potentials have been made in 16 adult cats with acute spinal cord injuries produced experimentally in which myelotomy was performed in 8 cats 1 hour after the injury. The remaining 8 animals served as control. The spinal cord injury with 20gm - 20 cm was inflicted over the entire dorsal surface of the spinal cord at L2-3 interspace by Allen's weight-drop method which was improved by placing a curved steel plate anterior to the spinal cord to provide a smooth, hard surface for the receipt of posterior cord impact. Under the operating microscope, a median posterior longitudinal myelotomy approximately 10mm to 15mm in length was made at the injury site 1 hour after the injury. Animals were evaluated electrophysiologically either from preinjury state to postinjury 4 hours(control group) or from preinjury state to post myelotomy 3 hours(myelotomy group). The component waves of the spinal somatosensory evoked potentials(SSEP) of control group disappeared sequentially after the injury in the following order : N4, N3, N2, N1. In myelotomy group, N4 and N3 wave also disappeared, but N1 and N2 wave remained. The latencies of the component waves increased & its amplitudes decreased sequentially after the injury. In myelotomy group, as com-with the control group, post-traumatic latency rate increase as well as amplitude were both reduced.

The Study on Experimental Brain Herniation

Cerebral herniations were successfully produced in experimental animals during the expansion of intracranial balloon or laminaria. Visualizing structures deep in the brain, cat's heads were instantaneously frozen with liquid nitrogen and were sectioned in the midline longitudinally. The cerebral herniations were assessed by measureing the distance between parts of various anatomical structures on the brain in mid-sagittal sectional plane. Transtentorial rostrocaudal herniation of the brain stem was evident and more marked in the group of bilateral lesions than in the groups of frontal and temporal lesions. Infratentorial lesions produced transtentorial upward herniation of a part of anterior cerebellar vermis and downward herniation of the cerebellar tonsil through the foramen magnum. The risk of brain herniation was noted to be greater in rapid expanding lesions with balloon than the more slowly developing lesions with laminaria.

Experimental Study on Local Hypothermia in the Spinal Cord

A study of effect of local hypothermia upon the spinal cord was performed in cats. With a cuff, a cooler, to which was attached connecting tubes to a refrigerator, the experimental technique was deviced to cool the spinal cord locally at midthoracic level. Cold liquid, saline at a temperature of +/-1.1 degrees C, was circulated in closed system through the tubing into the cuff which was snugly rested on the dorsal surface of the spinal cord as a heat exchanger. The temperatures were measured with thermocouples at various sites in the spinal cord before, during, and after the cooling every two minutes upto twenty minutes. In the cord underneath the cuff, the mean precooling temperature of 35.4 degrees C in normal control group was lowered to 11.0 degrees C during the first two minutes of cooling. After this in initial rapid drop in temperature, there was a further gradual reduction of 4.5 degrees C upto 20 minutes cooling to be 6.5 degrees C. The lowest mean temperatures recorded throughout cooling were 4.3 degrees C at dorsal surface and 6.9 degrees C at center of the cord. And the temperature lowering was nearly not noted beyond the cord 1 cm apart from an edge of cuff in rostral and caudal directions. For comparison, the temperature in the cord that had not been injured was also measured. The rate of cooling in the cord underneath the cuff seemed to be faster than in the control group of animal in which the cord was not injured. Another design of this experiment was an evaluation of the protective effect of local hypothermia with respect to cord edema and injury associated cord hemorrhage. Immediately after intravenous administrations of fluorescin the spinal cords were contused with impaction injury. These injured cords were removed ar different time intervals after trauma, and spread or distribution of fluorescin in frozen sectioned specimens was observed under ultraviolet illumination with fluorescence microscope. In all cooling groups, pathological pictures were reduced in its degree and extent more than those in the control group, and that, earlier the cooling after the injury to the cord, better the result was outcome. It would be well to say that local hypothermia might be within the margin of safety and beneficial in the management of spinal cord injury in this experiment.

A Case of Tuberculoma in Posterior Fossa

The incidence of tuberculoma of the brain in different countries varies reatly. They form a high percentage of intracrnial lesions dealt with in countries of Asia, Eastern Europe, Italy, Spain and South America. The recent introduction of the potent antituberculosis remedies, far from diminishing the incidence of tuberculoma of the brain, is more likely to increase it. This case was a 18 year old male who had increased intracranial pressure signs and characteristic signs which was suggestive lesion in posterior fossa. Conray ventriculography revealed nearly total obstruction of distal portion of aqueduct of Sylvius with displacement to the right side. Intensive antituberclous treatment then was started after removal of tuberculoma in cerebellar vermis and then discharged with fully recovery. References were reviewed as will.

A Case of Tuberculoma in Posterior Fossa

The incidence of tuberculoma of the brain in different countries varies reatly. They form a high percentage of intracrnial lesions dealt with in countries of Asia, Eastern Europe, Italy, Spain and South America. The recent introduction of the potent antituberculosis remedies, far from diminishing the incidence of tuberculoma of the brain, is more likely to increase it. This case was a 18 year old male who had increased intracranial pressure signs and characteristic signs which was suggestive lesion in posterior fossa. Conray ventriculography revealed nearly total obstruction of distal portion of aqueduct of Sylvius with displacement to the right side. Intensive antituberclous treatment then was started after removal of tuberculoma in cerebellar vermis and then discharged with fully recovery. References were reviewed as will.