Dizziness when eating: an unusual isolated presentation of cerebral venous thrombosis.

A previously healthy 60-year-old man had a two-year history of dizziness or faintness when eating but not when drinking. MRI of the brain detected deep venous dilatation, and digital subtraction cerebral angiography showed superior sagittal sinus thrombosis. These symptoms were completely resolved after the daily administration of 200 mg ticlopidine for four weeks. The pathomechanism of this unusual presentation is speculated episodic congestion of the jugular venous drainage during mealtime due to an increase in the circulatory volume of the external carotid-jugular system.

Evaluation of the internal thoracic arterial graft patency by the transthoracic Doppler method under continuous intravenous infusion of adenosine triphosphate disodium.

Usefulness of the Doppler method under continuous infusion of adenosine triphosphate disodium (ATP) for improvement of accuracy in the diagnosis of the left internal thoracic arterial graft (LITA) patency was examined using transthoracic ultrasonic echocardiography. 1) Influence of ATP on the Doppler velocity in a graft was examined in 7 patients with good LITA grafts using physiological saline as the control. In the ATP group, 80 mg of ATP was dissolved in 20 ml physiological saline and continuously infused at 0.14 mg/kg/min. In the saline group, an equal volume of physiological saline was administered and the blood flow velocity in the LITA was recorded continuously by the transthoracic Doppler method from the supraclavicular fossa approach. Results; ATP administration increased the blood flow velocity in the LITA and the rate of increase was 48.3% for systolic peak velocity, 111% for diastolic peak velocity, 64.4% for systolic time velocity integral and 99% for diastolic time velocity integral indicating particularly high rates of increase in diastolic components. The diastolic/systolic peak velocity ratio or diastolic fraction did not increase significantly. In the saline group, none of the parameters showed a change. 2) Angiographic findings of the LITA were compared with the measurement values of the diastolic components by the Doppler method to examine usefulness of diastolic component measurement with ATP infusion for diagnosis of LITA patency. Subjects were 19 patients with good LITA (group A) and 8 patients with bad LITA (group B). Results; while there were significant differences in the mean baseline diastolic peak velocity, mean diastolic time velocity integral and mean diastolic fraction between the groups, overlapping was seen in individual cases. However, the inter-group differences were more distinct by ATP infusion and the borderline values were 30 cm/sec for diastolic peak velocity and 10 for diastolic time velocity integral. 3) Reliability of the diagnosis for LITA patency by measuring the diastolic components using the Doppler method with ATP infusion was examined and compared with the angiographic findings as the gold standard. Subjects were 27 patients and the diagnostic criteria for good LITA were set at 30 cm/sec for diastolic peak velocity and 10 for diastolic time velocity integral. Results; sensitivity and specificity of the Doppler method with ATP infusion were 100% for diagnosis of LITA patency by measuring the diastolic components. Conclusion, in diagnosis of LITA patency by the transthoracic ultrasonic cardiography, diagnostic accuracy was improved by measuring the diastolic parameters under continuous infusion of ATP.

Long term melphalan-prednisolone chemotherapy for POEMS syndrome.

The effects of long term melphalan-prednisolone (MP) therapy was studied on 12 patients with POEMS (polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes) syndrome. Six were treated with MP every six weeks for 16 to 52 months; three also with cyclophosphamide, and three with localised irradiation for osteoclastic lesions. Five of the six survived during the follow up period and showed various degrees of lessening of their neuropathy and other symptoms. There were no serious side effects. The other six patients received treatments that included corticosteroids, short term chemotherapy, or irradiation, but not long term chemotherapy. Five showed transient lessening of their non-neurological symptoms, and one, obvious neurological improvement. Five of these six patients died from nine to 70 months after POEMS onset. The findings suggest that long term MP therapy may be an effective treatment for the POEMS syndrome.

Effect of cromakalim on ischemic and reperfused immature heart: experiments with isolated neonatal New Zealand white rabbit hearts.

To elucidate whether K+ channels are involved in the ischemia-reperfusion injury in immature heart, we examined the effect of cromakalim, a potent opener of ATP-sensitive K+ channel (KATP channel), on the ischemic and reperfused neonatal New Zealand white rabbit heart. The experiments were divided into control group and cromakalim pretreated group. When, the heart was loaded with 10 microM cromakalim preischemically, the recovery of heart rate and left ventricular developed pressure were significantly improved than those of the control group. Pretreatment with cromakalim also decreased lactate excretion in the coronary effluent. Measurements of cation contents with atomic absorption method revealed that intracellular K+ content was lower in cromakalim pretreated group at preischemia, end of ischemia and 20 min after ischemia. Intracellular accumulation of Na+ and Ca2+ at reperfusion period was inhibited by cromakalim pretreatment. From these results, it is assumed that cromakalim might act on KATP channels of plasma membrane and reduces the K+ content of the cardiomyocytes which in turn inhibits Na+ and Ca2+ accumulation during the reperfusion period. Prevention of Na+ and Ca2+ accumulation after ischemia might be a reason for cardioprotective effect of cromakalim on neonatal New Zealand white rabbit heart.

[Surgical experience of two different types of unroofed coronary sinus].

We experienced two cases with uncommon unroofed coronary sinus. The first patient, a 55-year-old man, had a partially unroofed mid-portion of the coronary sinus. His symptoms and physical state were similar to that of atrial septal defect (ASD). Echocardiogram and angiogram revealed that the coronary sinus (CS) communicated with the left atrium (LA). We confirmed that CS had an enlarged orifice and lacked a part of its roof through the right atriotomy and the atrioseptotomy. We directly closed the defect between the LA and the CS. His postoperative course was satisfactory. The second patient, a 46-year-old man, showed mild cyanosis. He had a completely unroofed CS with left superior vena cava (LSVC), absent inferior vena cava (IVC) and hemiazygos continuity. The LSVC directly drained to the LA, and the CS was absent. A part of the posterior wall of the LA was like a groove which laid from the orifice of the LSVC to the coronary sinus ASD. The roof of this groove was covered with fibrous tissue, which was shaped like a network structure. We thought that this network was a residue of the septum between the CS and the LA. Thus we resected this structure, and reconstructed the roof by equine pericardial patch to drain the venous blood from the LSVC to the right atrium. Anomaly in the patient may be the transitional type between the completely unroofed CS and the partially unroofed CS.

[Recurring consciousness disturbance with elevation of endogenous benzodiazepine-like activity].

A 63-year-old man had recurrent spontaneous attacks of consciousness disturbance without toxic, metabolic, or structural brain damage. Interictal electroencephalography showed 14 Hz spindle wave-like activity; ictal electroencephalography revealed faster basic activity. Flumazenil, a benzodiazepine antagonist, promptly resolved the attacks. The endogenous benzodiazepine-like activities in plasma and cerebrospinal fluid (measured in the courtesy of P. Schoch Ph. D, F. Hoffmann-La Roche Ltd, Basel, Switzerland) increased in the interictal period and increased more strikingly in the ictal period. These findings and the clinical effects of flumazenil suggest an involvement of an endogenous benzodiazepine-like activity in the pathogenesis of the attacks in this patient, as same as in a case reported by Tinuper et al (1992).

[Hemoptysis due to aortopulmonary fistula: a case report of successful surgical treatment].

A 76-year-old man was admitted for recurrent hemoptysis of 3 weeks' duration. Chest X-ray revealed lung emphysema, but no findings of thoracic aortic aneurysm. The patient's physician attributed to bronchoectasia, and he underwent angiography for the purpose of embolization of bronchial arteries. Angiography showed a small saccular thoracic descending aortic aneurysm and an aortopulmonary fistula. So aneurysmectomy and patch angioplasty was done under partial cardiopulmonary bypass. Lobectomy or wedge pulmonary resection was not necessary. His postoperative course was uneventful. In case of the patients with hemoptysis, the possibility of aortopulmonary fistula should be considered, and computed tomography or aortography should be done to rule out other pulmonary diseases.

Associated movement as a sequel to thoracotomy: aberrant regeneration to the latissimus dorsi muscle.

We describe two patients with unusual associated movements as a sequel to thoracotomy. The two patients developed involuntary twitchings of the latissimus dorsi, which were induced by contractions of the adjacent muscles, the serratus anterior muscle in patient 1 and the external intercostal muscle in patient 2, after lobectomy for lung cancer. Electrophysiological and radiological studies showed that aberrant regeneration from the adjacent nerves to the denervated latissimus dorsi could be responsible for the associated movements.

[Multivariate analysis of spinal automatism in neurological diseases].

We investigated the relationship between spinal automatism (SA) and other neurological signs and symptoms (pyramidal, extrapyramidal, cerebellar, autonomic) by multivariate analysis in cervical spondylotic myelopathy (CSM) 112 cases, amyotrophic lateral sclerosis (ALS) 121 cases, and multiple system atrophy (MSA) 115 cases (olivo-ponto-cerebellar atrophy (OPCA) 55 cases, Shy-Drager syndrome (SDS) 42 cases, striato-nigral degeneration (SND) 18 cases). SA elicitation maneuver we used was pinprick stimulation at the dorsal pedal skin, and all cases showed twitched or phasic triple flexion pattern. As SA was elicited in 19 cases in CSM (17.0%), 23 cases (19.0%) in ALS, 36 cases (31.3%) in MSA, SA was more elicited in MSA than in ALS and CSM (p < 0.05, p < 0.01 by chi-squared test). In MSA, SA tended to be elicited more likely in SDS (21 cases, 50.0%) and in SND (8 cases, 44.4%) than in OPCA (7 cases, 12.7%) (p < 0.01 by chi-squared test). In MSA, the longer the duration of the disease became, the more SA was elicited, but not in ALS and CSM. Multivariate analysis (quantification method type II) showed that clinical signs as a statistical contribution factor for SA elicitation ranked Babinski's sign, micturition disturbance in ALS and CSM and Babinski's sign, orthostatic hypotension in MSA in order: In all 3 diseases, Babinski's sign and autonomic disturbance ranked higher. This conclusion suggested that SA was not always related to the pyramidal tract damage and was associated with the damage of small myelinated fibers in and/or around the pyramidal tract.