[Two cases of delayed posttraumatic vasospasm followed by brain SPECT].

This is a report of two cases of delayed posttraumatic vasospasm. In case 1, a 68-year-old male was injured by falling. He did not show any neurological deficits on admission. CT scan revealed a diffuse subarachnoid hemorrhage (SAH) without brain contusion. Aneurysm was not disclosed by angiography. On the 7th day after admission, he presented disorientation. Reviewed angiography revealed diffuse delayed vasospasm. 123I-IMP brain SPECT showed an extensive low perfusion area in the bilateral parietal portion. In case 2, a 71-year-old female experienced immediate development of a deep comatose state after head injury. CT scan on admission disclosed a massive acute left subdural hematoma and the severe compression of the left cerebral hemisphere by the hematoma. But traumatic SAH was not diffuse and was restricted to the left basal cistern. After emergency operation, her consciousness level improved and the mass effect of the subdural hematoma was diminished. On the 7th day after the operation, her neurological condition worsened. CT scan showed some infarction lesions in the left cerebral hemisphere and mild left cerebral swelling. Angiography on the same day revealed vasospasm in M2-M3 portion of left middle cerebral artery. HM-PAO brain SPECT disclosed low perfusion in the left parietal region, but a state of high perfusion in the other region. In case 1, vasospasm might have been derived from diffuse clots of traumatic SAH caused by the same process as postruptured aneurysmal vasospasm. In case 2, the region of vasospasm was not associated with traumatic SAH. It corresponded to the site of the brain contusion. It was suggested that the cause of vasospasm might have been the direct mechanical injury to the arterial wall and chemical substances deriving from the contused brain tissues. We conclude that SPECT or transcranial Doppler monitoring should be used for the early detection of posttraumatic vasospasm.

[Two cases of neurogenic bladder due to HTLV-1 associated myelopathy (HAM)].

Case-1 (24-year-old female) had complained of slowly progressive urinary incontinence (since 14 years old) and gait disturbance (since 18 years old). A marked pyramidal disorder was observed, and anti-HTLV-1 antibody (1:640) was present in her peripheral blood. She was diagnosed as having HTLV-1 associated myelopathy (HAM). Repeated urodynamic studies (UDS) revealed exacerbation of overactive bladder and detrusor-sphincter dyssynergia (DSD) with the progress of the disease. Case-2 (48-year-old male) had complained of gait disturbance (since 32 years old) and progressive urinary hesitancy (since 46 years old). Physical examination revealed a marked pyramidal disorder. Anti-HTLV-1 antibody (1:200) and ATL-like cells were present in his peripheral blood. He was diagnosed as having HAM. The voiding cystourethrography demonstrated an abnormal change of the bladder wall. UDS revealed overactive bladder and marked DSD. Medications based on adrenocortical steroids and urological cares have improved urinary disturbance, in both cases.

[A case of neurogenic bladder due to arachnoid cyst of the middle cranial fossa].

A 6-year-old girl, with urinary incontinence for the past 3 years, showed an overactive bladder and detrusor-sphincter dyssynergia (DSD) in urodynamic study. An epileptic focus in the right occipital area, as well as a large arachnoid cyst in the left middle cranial fossa was revealed by EEG and intracranial CT. After surgery for the arachnoid cyst, urinary incontinence was improved with disappearance of the epileptic focus in EEG, and an alteration of overactive bladder into normolactive one and improvement of DSD were observed in urodynamic study. It was considered that the urinary incontinence of this case might be associated with the ectopic epileptic focus due to the arachnoid cyst.

[Clinical study on developmental hydrocephalus and its operative timing in lumbo-sacral meningomyelocele].

Nine infants with lumbo-sacral meningomyelocele were evaluated in the diagnosis and the operative timing of hydrocephalus. Seven cases received early operation for meningomyelocele within 36 hours after birth. Two cases with closed meningomyelocele were operated on 8 days and 32 days after birth. All of them were not infected in the central nervous system before and after its surgery. Five out of nine cases had rapidly developed hydrocephalus within a few weeks, and received ventriculo-peritoneal shunt (Shunt group: Case1-5). Two cases with gradual enlargement of the lateral ventricles and two cases with normal development have been observed without shunt procedure (Non-shunt group: Case 6-9). The authors recorded the head circumference, Evans' index on CT, and intracranial pressure of those infants at birth and following days. The head circumference at birth was almost within a normal size in both groups. On the other hand, an average of Evans' index in shunt group at birth was greater than that of non-shunt group. Moreover, the growth rate of head circumference and lateral ventricle of shunt group were more markedly increased than that of non-shunt group. The head circumference and the ventriculomegaly on a computed tomography at birth were poor prediction of hydrocephalus, however, there was positive correlation between the rate of head growth and the rate of hydrocephalic development. That is to say, the growth rate of a head circumference and growth of Evans' index suggested the prediction of a progressing hydrocephalus during the first few weeks.

[Percutaneous transabdominal fine needle aspiration of regional lymph nodes in genitourinary cancer].

Percutaneous fine needle aspiration of retroperitoneal pelvic and abdominal lymph nodes was done in 21 patients with clinically localized bladder, prostate, or penile cancers. A diagnosis of metastases to regional lymph nodes was detected by this method in 6 patients, but only one case could be diagnosed by bipedal lymphography. Positive aspiration results may spare the patient with prostatic or bladder cancer an unnecessary radical operation. This method also enables the detection of micrometastasis of lymph node which can not be detected by lymphography. No complications were seen in this series.

[Hypothalamic histiocytosis X--report of a case].

Histiocytosis X is a non-neoplastic disorder of unknown etiology characterized by a mass of proliferating histocytes, plasma cells and inflammatory cells forming a granuloma within the reticuloendothelial elements of any organ system in the body. The three clinical syndromes of this condition, eosinophilic granuloma, Hand-Schüller-Christian disease and Letterer-Siwe disease were unified into a single nosological entity by Lichtenstein in 1953. The complication of the central nervous system is shown in the cerebrum, cerebellum, sella turcica, hypothalamus and so on. Hypothalamic histiocytosis X is often found in cases of disseminated histiocytosis X, but an isolated histiocytosis X of the hypothalamus is very rare. Including our case, 16 cases of hypothalamic histiocytosis X were reviewed in this paper. Age at onset was older than disseminated histiocytosis X. The sex ratio was almost equal. Diabetes insipidus was equally found as in other suprasellar masses and it was important as an initial symptom. The CT finding was shown as a homogeneously enhanced mass but no specific finding of CT was seen as suprasellar histiocytosis X. Therefore, differential diagnosis was very difficult. Treatments for this disease were variable. Chemotherapy, irradiation or combination of both were reported. The combination therapy was thought to be the most effective treatment. The relation between this disease and disseminated histiocytosis X is not known. But possibility of transformation of this disease into disseminated histiocytosis X was reported in some papers. Therefore, early diagnosis by biopsy of the hypothalamic lesion was stressed.

[Fracture of the sella turcica--a case report and review of the literature].

The incidence of a fracture of the sella turcica is reported to be rare and the authors reported a case of a sellar fracture associated with several neurological and endocrinological complications. A 16-year-old boy was struck at the face and the forehead on the road in a motorcycle accident and was hospitalized in a confusional state. Neurological examinations showed dilatation of the both pupils, sluggish light reflex on both sides and bilateral oculomotor palsy but motor weakness or sensory disturbance was not present. On the tenth hospital day, he developed diabetes insipidus and endocrinological examinations disclosed the impairment of GH, LH and FSH reserves, too. Neuroradiological examinations disclosed fractures of bilateral frontal bones and fractures of the left optic canal and ethmoidal roof as well as a fracture of the sella turcica. On the 28th hospital day, he also developed CSF rhinorrhea and pneumocephalus. Surgical repair for the CSF rhinorrhea was performed. Fractures of the sella turcica were reviewed in 23 cases including our personal case and a special consideration regarding the mechanism of sellar fractures and their major complications was made. The authors stressed the early recognition of a fracture of the sella turcica in head injuries, which would suggest a severe hypothalamo-pituitary involvement or other neurological disorders.