Transorbital-transpetrosal penetrating cerebellar injury--case report.

A 4-year-old boy presented with a transorbital-transpetrosal penetrating head injury after a butter knife had penetrated the left orbit. The knife tip reached the posterior fossa after penetrating the petrous bone. Wide craniotomy and the pterional, subtemporal, and lateral suboccipital approaches were performed for safe removal of the object. The patient was discharged with left-sided blindness, complete left ophthalmoplegia, and hypesthesia of the left face. Early angiography is recommended to identify vascular injury which could result in fatal intracranial hemorrhage.

Local hypercoagulative activity precedes hyperfibrinolytic activity in the subdural space during development of chronic subdural haematoma from subdural effusion.

The involvement of coagulation and fibrinolysis in the development of chronic subdural haematoma (CSH) from subdural effusion was investigated. Subdural fluid and venous blood samples were obtained from 34 patients with CSH and 9 patients with subdural effusion, and analyzed using enzyme-linked immunosorbent assays for thrombin-antithrombin III complex (TAT), prothrombin fragment F1 + 2 (F1 + 2), tissue factor, tissue factor pathway inhibitor (TFPI) and D-dimer. CSH was classified into the layering type, believed to be active, and other types according to x-ray computed tomography. All markers in the blood of both patient groups were similar to the values of normal subjects. Levels of TAT and F1 + 2 were much higher in the subdural fluid than in the blood of patients with CSH (P < 0.001, P < 0.001) and with subdural effusion (P < 0.05, P < 0.05). The level of D-dimer in the subdural fluid was significantly higher than in the blood (P < 0.001) in patients with CSH, but not in patients with subdural effusion. All markers in the subdural fluid of layering type CSH, except TFPI, were significantly higher than in the other types (P < 0.05). Local hypercoagulative activity in the subdural space is present in subdural effusion and precedes hyperfibrinolytic activity in CSH. Thrombin generation as indicated by TAT and F1 + 2 might be involved in the development of CSH. Propagation of CSH may be modulated by the coagulation system including the extrinsic pathway and fibrinolysis.

Inflammatory cytokines locally elevated in chronic subdural haematoma.

The involvement of inflammation in the development and propagation of chronic subdural haematoma (CSH) was investigated by measuring the levels of inflammatory cytokines (tumour necrosis factor [TNF] alpha, interleukin [IL]-1 beta, IL-6, and IL-8). Peripheral venous blood and subdural fluid were obtained at the time of burr hole surgery from 34 patients with CSH and from 9 with subdural effusion. The levels of the inflammatory cytokines were analysed by enzyme-linked immunosorbent assay. The blood levels of TNF alpha, IL-1 beta, IL-6, and IL-8 in both CSH and subdural effusion groups were almost within the range of normal subjects, and no differences were observed between the two groups. IL-6 and IL-8 in the subdural fluid were much higher than in the blood of both groups, and the levels in CSH patients were significantly higher (10 times) than in subdural effusion patients. Local elevation of inflammatory cytokines in the subdural space of both CSH and subdural effusion without systemic change suggests the presence of local inflammation in the two diseases. The same behavioural patterns of cytokines for these and higher levels of cytokines in the CSH also suggest that inflammatory cytokines may be involved in the continuous development from subdural effusion to CSH and propagation of CSH.

[Two surgical cases of tectal glioma].

Tectal glioma is rare and difficult to diagnose, and the tumor has been known as the tumor that gives no indication of the need for direct surgery because of its anatomical location. At present, MR imaging is available to detect the tumor and its location. We present two patients who underwent direct surgery. Case 1: A 18-year-old female was admitted with headache and nausea. MRI showed signs of stenosis of the aqueduct and a tumor of the tectal region. The tumor was removed partially. Histological examination of this tumor demonstrated a low grade astrocytoma. After surgery, hydrocephalus improved. Case 2: A 12-year-old boy was admitted with hydrocephalus detected by CT. MRI demonstrated a tumor of the midbrain without confirmation. He underwent a V-P shunt for hydrocephalus, and was discharged without any complaints. After 2 years, he was admitted again with shunt malfunction. After shunt revision, his consciousness recovered. However, Parinaud's sign appeared and patency of the shunt was unstable. MRI revealed a tumor of the tectal region and signs of stenosis of the aqueduct of Sylvius. The tumor was removed directly by the occipital transtentorial approach. The aqueduct was opened and a catheter was inserted from the 3rd to the 4th ventricle. Histological examination revealed a low grade astrocytoma. The patient followed a satisfactory postoperative course except for slight Parinaud's sign, and the V-P shunt was no longer necessary.

Carbon dioxide gas replacement of chronic subdural hematoma using single burr-hole irrigation.

In order to achieve complete irrigation, reduce air in the hematoma cavity, and obtain rapid reduction of the cavity without drainage, we use burr-hole evacuation of the hematoma followed by irrigation using physiologic saline solution and replacement of the hematoma with carbon dioxide (CO2) gas. We have treated 19 cases between the ages of 41 and 84. With the exception of one case with dementia of 5 years' duration, all cases were asymptomatic postoperatively. Computed tomography (CT) scans obtained immediately postoperatively showed the gas to fill the hematoma cavity, but on the following day, the gas and the hematoma cavity had nearly disappeared. There was no surgical mortality nor morbidity and there were no side effects of the CO2 gas. Recurrence was found in one case (5.3%). By filling the hematoma cavity with CO2, disappearance of the cavity is rapid and drainage is not needed. Moreover, this technique implies no restrictions on postoperative motility, and is thus suitable for elderly patients.

Pineal yolk sac tumor in a 65-year-old man.

A 65-year-old man presented with a case of pure yolk sac tumor in the pineal region. The patient was admitted with a gait disturbance and elevated alpha-fetoprotein levels in serum and cerebrospinal fluid. He underwent total resection of the tumor. Cisplatin-vinblastine-bleomycin therapy was interrupted because of severe syndrome of inappropriate secretion of antidiuretic hormone, and there was recurrence of the tumor. Five months after the operation, he died in spite of carboplatin-etoposide therapy. A review of the literature revealed no previous report of pineal yolk sac tumor in an elderly patient. Problems in the diagnosis and treatment of such cases are discussed.

[Transplantation of embryonal cerebral cortex to the adult rat cerebellum: the fiber connections made by cortical transplants and the cerebellum].

Fifteen-day-old embryonic neocortical tissue was transplanted into the mature cerebella of normal adult rats (Fischer 344) heterotopically. After 5-8 months, WGA-HRP was injected into the host inferior olivary nucleus, pontine raphe, pontine nuclei, and neocortical transplants, 0.3 microliter, 0.2 microliter and 0.05 microliter respectively. The animals were sacrificed 48 hours later, and the HRP positive neuron and nerve fibers were examined in the transplants and host brain stem. Other animals were sacrificed for anti-dopamine-beta-hydroxylase immunohistochemical study and electron microscopic observation. Anterograde and retrograde tracing methods with the HRP method revealed on the light microscopic level that the transplants had received afferents from the host's locus coeruleus, and the inferior olivary nucleus. In one case, HRP injected into the host inferior olive was almost limited within the inferior olivary nucleus. Therefore, HRP-labelled fibers in the cerebellum were thought to be climbing fibers. The climbing fibers from the host inferior olivary nucleus entered the transplant from the host cerebellar medullary layers and branched in the transplant. The fiber ingrowth was limited within 300-500 microns for the distance. In another case, HRP injected into the inferior olive extended to the lateral reticular and the pontine nuclei. HRP labelled fibers entered the graft from the host medullary layers and many granular patterns like axon terminals were observed in the graft. In cases, in which HRP was injected into the pontine raphe and pontine nuclei, HRP labelled fibers did not grow into the graft. Retrograde tracing method with HRP injected into the graft showed labelled neurons in the host locus coeruleus.(ABSTRACT TRUNCATED AT 250 WORDS)

[Two cases of cerebral aspergillosis with intracerebral hemorrhage].

Two patients who had cerebral aspergillosis with massive intracerebral hemorrhage were presented. Case I was a 59-year-old woman who had slight mental retardation. There was swelling in the left forehead, from which mucosal cysts of frontal sinus had been removed 2 years before her admission. She had a diagnosis of subdural abscess and radical operation was performed. Aspergillus was found in the abscess histologically. Three months after the operation, CT scan revealed multiple abscess in bilateral frontal lobe. When she lost consciousness suddenly 4 months after the operation, CT scan showed a huge intracerebral hematoma. Case 2 was a 16-year-old girl who suffered from immunological dysfunction caused by more than 6 months antibiotics-steroid treatment for pneumonitis. She lost her consciousness after complaints of severe headache. CT scan showed a heterogeneous high density area with severe brain edema in the left temporal lobe. The removal of hematoma was performed immediately. The level of her consciousness improved, but she died of the complication of DIC and renal failure 14 days after the hemorrhage. Autopsy revealed a number of aspergillomas in lungs, kidneys, gastrointestinal tract, liver and pancreas. Marked necrosis and a number of aspergillus hyphae which invaded and penetrated the wall of cerebral vessels were found in the brain tissue. It was presumed that such a huge intracerebral hematoma was caused by direct invasion and penetration into the brain of aspergillus from the blood vessels. The diagnosis of cerebral aspergillosis is made mainly by the pathological examination of the tissue obtained at surgery or autopsy.(ABSTRACT TRUNCATED AT 250 WORDS)

Grafted granule and Purkinje cells can migrate into the mature cerebellum of normal adult rats.

Cerebellar primordia of different ages (embryonic days of 14 to 20) were transplanted into cerebella of normal syngeneic adult rats (Fischer 344). After 1-12 months (mostly 5-6 months), the host brains were examined by light and electron microscopy. In about 80% of our successful experiments, grafted Purkinje and/or granule cells migrated into the host molecular layer. Some granule cells migrated down along host Bergmann glia, reminiscent of their normal developmental migration route. Other granule cells migrated along astroglial processes that ensheathed capillary walls. Some grafted Purkinje cells were also located ectopically in the host molecular layer. They were identified as graft origins autoradiographically. This migration seemed to be encouraged under conditions where the subjacent host Purkinje cells had been lost. Where the grafted Purkinje cells were located on top of the host molecular layer, their primary dendrites faced vertically downwards into the host molecular layer. However, the position of the apical poles of migrated Purkinje cell bodies in the deeper aspect of the molecular layer varied considerably, suggesting that the orientation of the Purkinje cell dendrites is probably determined by the availability of afferent fibers. Thus, the present study has demonstrated that Purkinje and granule cells can migrate from embryonic cerebellar grafts into the molecular layer of the normal, adult host rat cerebellum.