Reappraisal of early CT signs to predict the arterial occlusion site in acute embolic stroke.

OBJECTIVE: To elucidate the value of early computed tomographic (CT) signs of stroke in predicting the occlusion site in the cerebral arteries. PATIENTS: 105 consecutive patients with acute embolic stroke affecting the anterior circulation. METHODS: Four early signs were evaluated on cranial CT within six hours of stroke onset: loss of the insular ribbon (LIR); attenuation of the lentiform nucleus (ALN); hemispherical sulcus effacement (HSE); and the hyperdense middle cerebral artery sign (HMCAS). The arterial occlusion site was definitively identified on cerebral angiography within two hours of the CT examination. RESULTS: LIR was present in 55% of patients with internal carotid artery occlusion. ALN was present in 65% of patients with occlusion of the sphenoidal portion (M1) of the middle cerebral artery. HSE was present in 47% of patients with middle cerebral artery branch occlusion. LIR was related independently to internal carotid artery occlusion (odds ratio (OR) 2.8 (95% confidence interval, 1.2 to 6.8)), ALN to M1 occlusion (OR 2.9 (1.2 to 7.4)), and isolated HSE without ALN or LIR to branch occlusion (OR 12.8 (3.2 to 51.5)). The combined presence of the three signs was indicative of internal carotid artery occlusion (p < 0.05), and the presence of ALN and LIR without HSE was indicative of M1 occlusion (p < 0.05) by univariate analysis. HMCAS bore no relation to either arterial occlusion site. CONCLUSIONS: LIR, ALS, HSE, and combinations of these were useful predictors of the arterial occlusion site.

Inhibition of Na+/H+ exchanger reduces infarct volume of focal cerebral ischemia in rats.

Activation of Na+/H+ exchanger (NHE) may have an important role in ischemic cell death by means of intracellular overload of Na(+) and Ca(2+). Recent evidence has suggested that inhibitors of NHE have protective effects on myocardial ischemia both in vivo and in vitro. In this study, we tested the hypothesis that FR183998, an inhibitor of NHE, reduces infarct volume produced by focal cerebral ischemia in rats. We used 20 male spontaneously hypertensive rats. Either FR183998 (1 mg/kg; n=10), or vehicle (n=10) was given intravenously to the rats and the distal middle cerebral artery of each animal was occluded using a photothrombotic technique. We measured regional cerebral blood flow using laser-Doppler flowmetry throughout the experiments. After 3 days, infarct volume was measured in each animal group. To estimate the brain edema, we also calculated the cortical volume in both hemispheres. The infarct volume in the FR183998-treated group (82+/-8 mm(3), mean+/-S.E.M.) was significantly smaller than that in the control group (115+/-12 mm(3)) (P=0.034). The cortical volume of the occluded side in the FR183998-treated group (359+/-7 mm(3)) tended to be smaller than that in the control group (378+/-9 mm(3)) (P=0.116). The regional cerebral blood flow and physiological variables during ischemia were not significantly different between the two groups throughout the experiments. These results suggest that inhibition of NHE by FR183998 may have beneficial effects in reducing infarct volume and brain edema during cerebral ischemia. Thus, NHE may play an important role in the development of neuronal damage during acute cerebral ischemia.

Attenuation and recovery of brain stem autoregulation in spontaneously hypertensive rats.

Cerebral large arteries dilate actively around the lower limits of CBF autoregulation, mediated at least partly by nitric oxide, and maintain CBF during severe hypotension. We tested the hypothesis that this autoregulatory response of large arteries, as well as the response of arterioles, is altered in spontaneously hypertensive rats (SHR) and that the altered response reverts to normal during long-term antihypertensive treatment with cilazapril, an angiotensin-converting enzyme inhibitor. In anesthetized 6- to 7-month-old normotensive Wistar-Kyoto rats (WKY), 4- and 6- to 7-month-old SHR without antihypertensive treatment, and 6- to 7-month-old SHR treated with cilazapril for 10 weeks, local CBF to the brain stem was determined with laser-Doppler flowmetry and diameters of the basilar artery and its branches were measured through a cranial window during stepwise hemorrhagic hypotension. The lower limit of CBF autoregulation shifted upward in untreated SHR to 90 to 105 mm Hg from 30 to 45 mm Hg in WKY, and it reverted to 30 to 45 mm Hg in treated SHR. In response to severe hypotension, the basilar artery dilated by 21 +/- 6% (mean +/- SD) of the baseline internal diameter in WKY. The vasodilation was impaired in untreated SHR (10 +/- 8% in 4-mo-old SHR and 4 +/- 5% in 6- to 7-month-old SHR), and was restored to 22 +/- 10% by treatment with cilazapril (P < 0.005). Dilator responses of branch arterioles to hypotension showed similar attenuation and recovery as that of the basilar artery. The data indicate that chronic hypertension impairs the autoregulatory dilation of the basilar artery as well as branch arterioles and that antihypertensive treatment with cilazapril restores the diminished dilation toward normal.

An ATP-sensitive potassium channel activator reduces infarct volume in focal cerebral ischemia in rats.

ATP-sensitive potassium channels are activated under hypoxic or ischemic conditions. The effects of ATP-sensitive potassium channel activators on cerebrovasculature and cerebral blood flow (CBF) are not well understood. We examined the effect of the ATP-sensitive potassium channel activator Y-26763 on focal cerebral ischemia in rats. In 24 spontaneously hypertensive rats, either Y-26763 (24 micrograms/kg) or vehicle was given by intracarotid infusion over 60 min, starting 30 min before photochemically induced thrombotic occlusion of the middle cerebral artery. CBF was measured by laser-Doppler flowmetry in the peri-ischemic penumbral cortex. Although Y-26763 lowered systemic blood pressure by 13 mmHg, the infarct volume assessed 3 days after the occlusion was significantly smaller in the Y-26763-treated group (n = 12, 71.2 +/- 22.0 mm3) than in the control group (n = 12, 94.7 +/- 20.4 mm3, P = 0.013). Y-26763 did not affect CBF before or after occlusion compared with CBF values of the control group. The results are consistent with the view that the activation of the ATP-sensitive potassium channel is neuroprotective in focal cerebral ischemia.

High speed detection of R-R intervals for universal Holter recordings.

Heart rate variability (HRV) has been gaining popularity for its potential to estimate the autonomic nerve function and prognosis of patients with cardiovascular diseases. Holter recordings have been used for the measurement of R-R intervals in out-patients and for the estimation of circadian variations of HRV. However, when the manufacturer of the Holter tape recorder is not the same as that of the Holter analyzer a correction of the tape speed error for the accurate measurement of the R-R intervals is abandoned. The simultaneous assessment of additional physical parameters recorded on the Holter recorder and R-R interval is not possible with commercial software. To overcome these problems, we developed a system to detect R-R intervals at the playback speed of a Holter analyzer 500 times real-time with the correction of tape speed error from a system clock recorded on the Holter tape. High- and low-pass filter processed ECG signals and a comparator provided digital signals representing the R-R intervals. The R-R intervals and system clock intervals (tape speed) were measured simultaneously by interrupt-driven software, using timer-counters in a personal computer. The measured R-R intervals were corrected with the system clock intervals. The power spectra of the tape speed error showed that tape speed error significantly affects the power spectra of HRV, if not corrected. This method is applicable to Holter tape recorders of any manufacturer. This system also enables the simultaneous measurement of HRV and other physical parameters to evaluate their relations.

Parallel recording of physical activity on commercial Holter recorders.

To accurately interpret heart rate variability (HRV) including circadian rhythm from Holter ECG, the simultaneous assessment of physical activity, which significantly affects HRV, is essential. In this study, to obtain this simultaneous assessment, the fundamental problems in implementing an accelerometer in a commercial Holter recorder were studied. In a treadmill exercise, three axial outputs of an accelerometer showed highly linear correlations with the running speed (correlation coefficient; vertical 0.94, forward-backward 0.97, sideways 0.97, three-dimensional amplitude 0.96, n = 8). The vertical acceleration showed a slightly sigmoidal increase with speed. Against a slope change, no significant increase in acceleration was observed except in the forward-backward direction. Individual calibration was found to be needed for the accurate estimation of physical load from body acceleration. A simplified calculation with the sum of the three axial absolute values correlated highly with the three-dimensional (3D) acceleration which shows the most reliable response to motions in any direction (r = 0.98, the slope of the regression line = 0.97) and, with this relation, the estimated 3D amplitude showed a sufficient degree of agreement. This substituted calculation was used in the Holter recordings. To know the posture of subjects, a piezoresistive accelerometer with the function of clinometer was used in another study. From played-back Holter recordings, the R-R interval and body acceleration were simultaneously sampled. The serial changes of both the power spectra of HRV and the body acceleration were observed over a 24 h period. Some cases with an abnormally reduced high-frequency component (HF) of HRV at night or an unusually high HF in the daytime were explained by physical conditions estimated with the accelerometer. The simultaneous assessment of patients' physical state by the present method provides the accurate interpretation of circadian rhythm in HRV.

Amlodipine, a Ca2+ channel antagonist, modifies cerebral blood flow autoregulation in hypertensive rats.

We measured the cerebral blood flow at rest and during hemorrhagic hypotension in 7 rats of each group using laser-Doppler flowmetry. Simultaneously, the absolute baseline cerebral blood flow values in the parietal cortex were quantified with the hydrogen clearance method. Baseline mean arterial pressure was significantly lowered, by 29 mm Hg, in the amlodipine-treated group, while the baseline cerebral blood flow was 36 +/- 4 ml/100 g/min (mean +/- S.D.) which was almost the same as the 40 +/- 5 in the control group. The lower limits of the cerebral blood flow autoregulation, defined as the mean arterial pressure at which the cerebral blood flow decreased by 10% of the baseline value, were shifted to a lower level of 107 +/- 9 mm Hg in the treated group compared with 133 +/- 5 mm Hg in the control (P < 0.001). The results demonstrated that, in hypertensive rats with amlodipine treatment, cerebral perfusion was preserved at a lower blood pressure level, which is advantageous under hypotensive conditions.

Altered cerebrovascular response to a potassium channel opener in hypertensive rats.

We examined whether the effect of Y-26763, an ATP-sensitive potassium channel opener, on cerebral blood flow is altered in stroke-prone spontaneously hypertensive rats (SHRSP) and, if altered, whether long-term antihypertensive treatment with cilazapril, an angiotensin-converting enzyme inhibitor, is capable of preventing the change. Cerebral blood flow during intracarotid infusion of Y-26763 was measured in anesthetized SHRSP and normotensive Wistar-Kyoto rats (WKY) as control. Y-26763 increased cerebral blood flow in a dose-dependent manner in WKY, and glibenclamide, a selective inhibitor of ATP-sensitive potassium channels, inhibited the Y-26763-induced increase in cerebral blood flow. In contrast, the response to Y-26763 in SHRSP was significantly impaired compared with that in WKY. Antihypertensive treatment with cilazapril lowered blood pressure toward normal and prevented the impaired response in cerebral blood flow to Y-26763 in SHRSP. These findings suggest that (1) ATP-sensitive potassium channels contribute to the regulation of cerebral blood flow in rats, (2) the response to an ATP-sensitive potassium channel opener is markedly diminished in hypertensive rats, and (3) the altered response to an ATP-sensitive potassium channel opener during chronic hypertension can be prevented by long-term antihypertensive treatment.

[Urinary incontinence in elderly patients in the chronic stage of stroke].

One hundred and six elderly patients with chronic stroke who were admitted to Seiai Rehabilitation Hospital were studied regarding urinary incontinence. The average age of the subjects was 74 +/- 8 years old, ranging from 60 to 94 years. Seventy three of the 106 patients (69%) had urinary incontinence which was found in 72% of brain infarction, 61% of brain hemorrhage and 67% of subarachnoid hemorrhage. The prevalence of urinary incontinence in cases of brain stem, thalamic, and putaminal hemorrhage was 80%, 67% and 46%, while that in cases of cortical infarction and infarct of perforating arteries was 84% and 68%, respectively. The rate of urinary incontinence was significantly higher in those aged 75 years or over (p < 0.05), those with poor activities of daily living (ADL, p < 0.005), or with dementia (p < 0.001). Dementia was a complicating factor more frequently in aged patients (p < 0.05) and in those with poor ADL (p < 0.001), although no correlation was seen between age and ADL (p = 0.08). These results indicated the high prevalence of urinary incontinence in elderly inpatients with chronic stroke, which is significantly related to impairment of mental and physical activities.

[Dose intensity in M-VAC chemotherapy with rG-CSF for metastatic transitional urothelial cancer].

The effect of M-VAC (methotrexate, vinblastine, adriamycin and cisplatin) chemotherapy supported recombinant human granulocyte stimulating factor (rG-CSF) was studied in 18 patients with metastatic urothelal cancer. The mean age of the patients was 66 years. Of the patients 6 had lung metastasis and 12 had distant lymph node metastasis. In this study recombinant human granulocyte stimulating factor was administered therapeutically at 100 to 250 micrograms subcutaneously after the white blood cell count was less than 3,000/mm. Relative dose-intensity (RDI) was 0.88 +/- 0.11 and 0.72 +/- 0.19 for 11 patients with rG-CSF and 7 without rG-CSF, respectively. The relative dose regardless of the interval of the cycle of M-VAC chemotherapy (%Dose) was 0.95 +/- 0.06 and 0.86 +/- 0.09 for the patients with rG-CSF and those without rG-CSF, respectively. Of seven patients without rG-CSF 3 patients responded (response rate 42%, mean survival period 7.4 months). Of 11 patients treated with rG-CSF 3 patients responded (response rate 72.7%, mean survival period 20.0 months). Although rG-CSF increased the RDI of M-VAC chemotherapy, the correlation of response with RDI was not clearly demonstrated. The therapeutical administrations of rG-CSF fail to improve the mean white blood cell nadir and to prevent the decrease of the platelet and reticulocyte count.

[Two cases of continent cystoileostomy using nipple valve method].

We performed continent cystoileostomy in which the technique of Kock's efferent nipple was utilized, on two female patients with urethral cancer and vulvar cancer. We recommend continent cystoileostomy for the patient who needs urethrectomy but whose bladder function can be preserved.

Testicular mast cell heterogeneity in idiopathic male infertility.

OBJECTIVE: To determine if the mast cell subclass changes in diseased testes. DESIGN: Retrospective. SETTING: University hospital urology clinic and anatomy laboratory. PATIENTS, PARTICIPANTS: Fourteen normal men and 50 patients with idiopathic male infertility. INTERVENTIONS: Histochemical techniques to identify proteoglycans of mast cells were applied to the obtained testicular biopsy specimens. MAIN OUTCOME MEASURES: The numbers of the heparin containing mast cell and the chondroitin sulfate containing mast cell were measured with light microscopy. RESULTS: The total number of mast cells and the ratio of chondoroitin sulfate containing mast cells were significantly increased in the testes from patients with idiopathic male infertility. CONCLUSION: These results suggest that mast cells may play a certain role in the etiology of idiopathic male infertility.

[Clinical characteristics and prognosis of renal cell carcinoma. Statistical evaluation of possible determinants for distant metastasis, venous tumor thrombi, and lymph node metastasis].

To clarify the recent clinical characteristics of renal cell carcinomas and to evaluate possible determinants for metastasis and venous tumor thrombi, the authors reviewed data from 99 renal cell carcinoma patients treated at Nagoya University Hospital between 1980 and 1989. According to Robson's classification, stage I tumors were found in 48 patients, stage II in 9, stage III in 16, and stage IV in 26. Incidentally detected tumors appeared to be on the increase in recent years. Grade 1 tumors were significantly associated with low-stage tumors and expansive growth. Univariate and multivariate analyses using a logistic regression model demonstrated that venous tumor thrombi and histological grade were significantly related to distant metastasis. Univariate analysis revealed relative risks of 4.7 for venous tumor thrombus presence (pV1b-pV2 vs. pV0-pV1a, p = 0.005) and 8.5 for histological grade (grades 2 and 3 vs. grade 1, p = 0.04). Local invasion (pT3 vs. pT2a-pTb: a relative risk of 7.5, p = 0.0009) and infiltration pattern (INF beta and INF gamma vs. INF alpha: a relative risk of 11.5, p = 0.002). were associated with venous tumor thrombi. Local invasion (pT3 vs. pT2a-pT2b: a relative risk of 6.6, p = 0.03) was the only significant determinant for lymph node metastasis. The 5-year actuarial survival rate was 60.0% for all 99 patients. The 5-year survival rates for stage I and II tumors were, respectively, 91.8% and 64.8%.(ABSTRACT TRUNCATED AT 250 WORDS)

[Studies on detection of serum IgA and IgG antibodies specific for Chlamydia trachomatis in latent infections in males].

We determined the serum concentrations of IgA and IgG antibodies specific for Chlamydia trachomatis (C. trachomatis) by an indirect immunoperoxidase assay (IPAzyme kit, Savyon Diagnostics, Ltd., Bee, Shova, Israel) to evaluate their diagnostic significance in latent infections in males. Forty-five asymptomatic males whose wife or partner was suspected to be infected with C. trachomatis were studied and the incidence of serum IgA (titer greater than or equal to 16) and IgG (titer greater than or equal to 64) antibodies for C. trachomatis was compared with that in a healthy group, a group with non-gonococcal urethritis (NGU) patients. Changes in IgA titer during treatment were also examined. The incidence of IgA and IgG antibodies in the healthy group was found to be 2.4% and 11.9% in males, and 4.8% and 18.1% in females, respectively. In patients whose wife or partner who was positive to C. trachomatis, the incidence of IgA and IgG antibodies was 42.2% and 75.6%, respectively. In the NGU patients the incidence of IgA and IgG antibodies was 56.3% and 62.5%, respectively. The incidence of IgA and IgG antibodies in patients whose wife or partner was antibody-positive were significantly higher (p less than 0.01) than the corresponding value in healthy men and women, but there was no significant difference from NGU patients or the elderly group. The IgA antibody titer during treatment of C. trachomatis infection showed no reduction in some cases. This study revealed frequent latent incidence of C. trachomatis infection in male patients. Determination of C. trachomatis IgA and IgG antibodies is considered to be supplemental for diagnosis of chlamydial latent infections.

Identification of collagens in the human testis.

SDS-PAGE of pepsin-solubilized collagens obtained from testes of elderly men revealed types I, III, V, and VI but not type IV. The total collagen content was 21.3 +/- 1.96% (mean +/- SD) as determined by hydroxyproline assay. The ratio for the pepsin-soluble fraction was 7.98 +/- 3.27%, i.e. very low as compared with other tissues. Type I collagen was determined by SDS-PAGE of cyanogen bromide cleavage of the pepsin-insoluble residue.

[A morphological study of the testes in patients with idiopathic male infertility--immunohistochemical analysis of collagens and laminin in human testes].

In the human testis, the distribution of extracellular components, such as types I, III, IV and V collagens and laminin, was investigated immunohistochemically by light microscopy. Specimens were obtained by testicular biopsy from 40 patients with idiopathic male infertility and 14 normal adult males. In the normal testes, the basement membrane was positive for types I, III, IV and V collagens and laminin. However, the distribution patterns of these components were different. Furthermore, a reactivity for types I and III collagens was found in the interstitial connective tissue matrix. Immunoreactivity for types I and III collagens was markedly positive in the limiting membranes around the Leydig cells. In the pathological testes, all the layers of the basement membrane of both thickened and obstructed tubules were positive for types I and III collagens. On the other hand, reaction products of type IV collagen were localized in the inner layer of the basement membrane and the peritubular cell (myoid cell) layer, and those of laminin were only found in the inner layer. Type V collagen-reactivity was observed in the basement membrane of thickened tubules. Positive reactions for types IV and V collagens and laminin were seldom recognized in the obstructed tubules. In the interstitial space, the connective tissues were significantly increased as compared with normal testes, which included extracellular components that reacted for types I and III collagens. Histological findings in normal adult testes and pathological testes were compared. Quantitative analysis of mean thickness of the basement membrane (W), mean seminiferous tubular diameter (T), T/W ratio and Leydig cell index demonstrated significant differences between the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of a 46XX male].

A 37-year-old man consulted our hospital with a complaint of male infertility. He was masculine but 159.9 cm in height. His beard, axillary hair and pubic hair were all normal. The penis and scrotum were also normal, but bilateral testes were very small (1 ml. respectively). Semen analysis revealed azoospermia. Endocrinological examination showed elevated serum lactating hormone and follicle stimulating hormone level, and extremely low level of serum testosterone. Testicular biopsy disclosed severely hyalinized seminiferous tubules and hyperplasia of Leydig cells. No ovarian tissue could be detected. The chromosomal analysis revealed a karyotype of 46 XX. This case was diagnosed as a case of 46XX male. The Japanese literature of 46XX male is reviewed.

[Clinical study of a modified Stamey's endoscopic bladder neck suspension procedure for one hundred female patients with stress incontinence].

One hundred female patients with stress incontinence have been operated on by means of modified stamey's endoscopic bladder neck suspension procedure, i.e. quantifying the thread tension for bladder neck suspension. Twelve patients had 1,000 grams in the nylon loop, 5,800 grams, 9,700 grams, 25,600 grams and 49,400 grams. A follow-up period varied from 10 to 32 months (mean: 20.5 months). A 60-min pad-weighing test revealed urinary loss of 1.0 to 196.0 grams/hour (mean: 36.0) prior to operation. 1. The modified Stamey's procedure was successful in 95 patients (95%). The appropriate thread tension for bladder neck suspension was 400 grams. 2. Various complications were encountered: removal of unilateral nylon suture was necessitated in 2 patients, bleeding from operative wound in 2, bladder tamponade in 2, and clean intermittent catheterization for more than one month in 4. 3. Micturition parameters, i.e. maximum and average flow rates, temporarily got worse post-operatively. Maximum urethral closure pressure decreased and functional profile length elongated which were significantly different from those of pre-operative values. 4. Questionnaire sent to the patients revealed that 89 percent of them were satisfied with the operative results but 11 percent were not. 5. The modified Stamey's procedure is simple to perform and prevents over-tightness of nylon loops. We conclude that this operative method is the treatment of choice for correction of stress incontinence.

[Ectopic ureteral opening: clinical assessment of 13 cases].

Thirteen cases of ectopic ureteral opening, surgically intervened during the past 10 years, were reviewed regarding the patients profiles, diagnostic procedure, treatment and concomitant anomalies. The diagnostic procedures are consisted of the conventional methods such as an intravenous urography, a vaginography, and a renoscintigraphy, which are important to identify and locate the immature kidney or the kidney with duplication anomaly. An angiographic examination is to be abandoned because it is invasive and rather insensitive. The surgical treatment should be determined depending on the renal function remained, ureteral morphology and the site of the ureteral opening.