Quality of life of Japanese elderly oral cancer patients during the perioperative period.

Japan's aging society has an increasing incidence of oral cancer. This study investigated perioperative changes in quality of life (QoL) among 172 oral cancer patients (elderly ≥75 years vs non-elderly <75 years), pre-treatment, at treatment completion, and at 1, 3, and 6 months post-treatment, using the following Functional Assessment of Cancer Therapy - Head and Neck (FACT-H&N) subscales: physical well-being (PWB), social/family well-being (SWB), emotional well-being (EWB), functional well-being (FWB), additional head- and neck-specific concerns (H&N). SWB (P=0.026), H&N (P=0.024), and total FACT-H&N (P=0.009) scores were significantly lower in the elderly group than in the non-elderly group at 6 months post-treatment, especially for mastication items (H&N1, P=0.047; H&N11, P=0.004), but not for swallowing items (H&N5 and H&N7, both P> 0.05). PWB (P= 0.004), EWB (P< 0.001), and FWB (P= 0.022) scores in the non-elderly group were significantly higher at 6 months post-treatment than before treatment. In the elderly group, no subscale showed a better score at 6 months post-treatment. Post-treatment QoL in elderly oral cancer patients did not improve, unlike in non-elderly patients.

Rupture of pial arteriovenous malformation associated with early thrombosis of the draining system following stereotactic radiosurgery--case report.

A 50-year-old man was treated with stereotactic gamma knife radiosurgery for an incidentally detected small callosal arteriovenous malformation (AVM) with stenosis of the main draining pathway. He suffered two episodes of intraventricular hemorrhage at 4 and 14 weeks after the radiosurgery. Radiological studies demonstrated that the anterior portion of the draining system including a varix, which had been irradiated, was thrombosed before the obliteration of arteriovenous shunts. Stereotactic radiosurgery is an accepted treatment for selected small and medium AVMs, but this procedure may increase the risk of bleeding. Early occlusion of a part of the draining pathway after stereotactic radiosurgery might have induced AVM rupture. An impaired venous outlet, either consisting of one draining vein or with stenosis, present before treatment may be develop thrombosis in response to high-dose irradiation.

The efficacy of coil embolization at the dissection site of ruptured dissecting vertebral aneurysms.

SUMMARY: Proximal occlusion of the parent artery has been widely used for treatment of vertebral dissecting ruptured aneurysms, but this does not always completely prevent re-rupture. In this series, the efficacy of occlusion at the dissection site using detachable coils was compared with proximal balloon occlusion. Over a five year period, 25 patients suffering from subarachnoid hemorrhage with dissecting vertebral aneurysms were treated by endovascular surgery. The first three of these 25 patients were treated with proximal balloon occlusion of the parent artery. The remainder underwent platinum coil occlusion at the affected site as early as possible after the diagnosis. In two of the three cases treated with proximal balloon occlusion, clipping or coating surgery were added because of progressive dissection. In all 22 cases of coil embolization, the intervention was successfully performed without complication. In one case with a dissection involving bilateral vertebral arteries, minor rebleeding from a contralateral dissection occurred after embolization. In the other 21 cases, rebleeding was not apparent (clinical follow-up: mean 24 months). Radiological findings showed complete occlusion of the dissection site and patency of the non affected artery (follow-up: mean ten months). We conclude that detachable platinum coil embolization at the dissection site is more effective than proximal occlusion for treatment of ruptured vertebral dissecting aneurysms because of immediate cessation of blood flow to the dissection site. However, in cases with bilateral dissections or hypoplastic contralateral vertebral arteries, preceding bypass surgery or stent treatment to preserve the affected vertebral artery may be needed.

The effect of encephalo-myo-synangiosis on abnormal collateral vessels in childhood moyamoya disease.

Child patients with Moyamoya disease initially present with ischemic symptoms. However, the long-term risk of intracranial hemorrhage for childhood Moyamoya disease is unknown. Hemodynamic overload to the fragile collateral vessels has been considered to cause hemorrhage. We reviewed angiograms to evaluate the effect of encephalo-myo-synangiosis (EMS) on abnormally dilated collateral vessels in 13 child patients with Moyamoya disease. EMS was performed on 24 sides in 13 patients ranging from 5 to 14 years of age. Post-operative angiography (6-88 months after surgery) revealed good revascularizations through EMS (larger than one-third of the middle cerebral artery (MCA) distribution) in 18 sides (75%) and smaller revascularizations in 6 sides (25%). In cases with a good revascularization through EMS, reduction of the abnormal collateral vessels was observed not only in the basal Moyamoya vessels (94% of sides) but also in the medullary arteries derived from the choroidal arteries (62% of sides), which are considered to cause intraventricular hemorrhages in adult patients. It is suggested that EMS may reduce the hemodynamic load on dilated collateral vessels and, subsequently, the long-term risk of intracranial hemorrhage in childhood Moyamoya disease.

The influence of vascular pressure and angiographic characteristics on haemorrhage from arteriovenous malformations.

BACKGROUND: The present study was designed to determine whether there is a physiological explanation for the predisposition of patients with certain angiographic characteristics to haemorrhage from cerebral arteriovenous malformations (AVMs). METHODS: Intra-operative measurement of feeding artery pressure (FAP) and intravascular pressures in the draining venous system [draining vein pressure (DVP) and cranial sinus pressure (SP)] were performed for 30 AVM cases using direct puncture of the vessels. The correlation between pressures and previously described angiographic characteristics predisposing to haemorrhage were evaluated. FINDINGS: Small nidus size and only one draining vein increased the risk of haemorrhage. FAP and DVP are both inversely related to the number of draining veins and the size of the AVMs. DVP was significantly higher in AVMs with haemorrhage (23.1+/-8.7 mmHg) than in those without (13.5+/-4.4), as was FAP (58.6+/-12.8 as opposed to 38.7+/-4. 7) (p<0.05). Moreover, the difference between systemic blood pressure and the FAP with haemorrhagic AVMs (17.0+/-9.5 mmHg) was significantly lower than that in nonhaemorrhagic cases (33.7+/-5.5) (p<0.05). The pressure difference between the feeding artery and draining vein was not significant between the haemorrhagic and nonhaemorrhagic groups. There was no significant difference of SP between haemorrhagic and nonhaemorrhagic patients. INTERPRETATION: The present study suggests that a high DVP probably induced by high resistance in the venous drainage system, as well as a high FAP, may contribute to the development of haemorrhage from AVMs, and physiologically supports previous reports that small AVMs and AVMs with only one draining vein are susceptible to haemorrhage.

Electron-Impact Total Ionization Cross Sections of Molecular Ions.

The Binary-Encounter-Bethe (BEB) model for electron-impact total ionization cross sections of neutral molecules has been modified for molecular positive ions. The total ionization cross sections for [Formula: see text], [Formula: see text], CD(+), and CO(+) from the modified BEB formula are compared to available experimental data. The theory is in good agreement with experimental data on [Formula: see text], [Formula: see text], and CD(+), but the experimental data by Belic et al. on [Formula: see text], and CO(+) are lower than the theory. The large difference between the theory and experiment on CO(+) is a strong indication of the dominance of the dissociative ionization channel, CO(+)→C(+)+O(+), which was not included in the experiment.

Spontaneous carotid cavernous fistulas with special reference to the influence of estradiol decrease.

The etiology of the dural arteriovenous fistula (AVF) involving the cavernous sinus is still unknown. However, it is of interest that this condition usually occurs in post-menopausal women. The purpose of the present study was therefore to clarify the relationship between sex hormone blood levels and the occurrence of dural AVFs in the cavernous sinus. Serum sex hormone levels and factors associated with atherosclerosis were examined in 26 consecutive patients with dural AVF involving the cavernous sinus presenting at our institute during the last eight years and compared with those of a post-menopause control group. Of the present patient series, 21 (81%) were women. All except five had passed menopause. Five (24%) of the women patients presented with symptoms consistent with cessation of menstruation, namely, a blood level of estradiol significantly lower than the control value. Hypertension was recognized in 10 (71%) of 14 females who had experienced menopause 10 or more years previously and in all male patients. A sudden abnormal decrease of blood estradiol levels in female patients demonstrating symptoms consistent with menopause may thus be an important precipitating factor in the occurrence of dural AVFs involving the cavernous sinus. Hypertension, in older female and male patients, with or without longstanding low blood estradiol levels, may cause atherosclerosis of the feeding vessels in the dura mater, resulting in the opening of a normal AV shunt to provide collateral circulation.

The factors influencing haematoma volume due to arteriovenous malformations.

Haemorrhage due to cerebral arteriovenous malformations (AVMs) varies from massive, requiring urgent operations, to clinically silent. The present study was designated to identify factors influencing haematoma size, and the pathophysiological mechanisms of massive haemorrhage were studied. 55 patients with intracerebral haematomas due to supratentorial AVMs were included in this study. Angiographic and clinical findings were retrospectively evaluated in relation to haematoma size. Statistical analysis demonstrated that small size and the presence of only one draining vein were high risk factors for massive haemorrhage. The haematoma volume in small AVMs (30 +/- 4 cm3) was significantly larger than in other AVMs (7 +/- 3 cm3) (p = 0.0005). AVMs with only one draining vein were associated with massive haematoma volume as compared to AVMs with two or more draining veins (30 +/- 4 versus 11 +/- 3 cm3, p = 0.0023). Our previous study demonstrated that feeding artery pressure (FAP) was significantly higher in AVMs with haemorrhage than in those without, as was draining vein pressure (DVP), and FAP and DVP were inversely related to the number of draining veins and the size of the AVMs. Thus, in small AVMs and AVMs with only one draining vein, local increase in DVP may thus contribute to massive haemorrhage.

The significance of hypothermic acid-base management induced before ischemia in a rat model of transient middle cerebral artery occlusion.

We investigated the effects of acid-base management during pre- and intra-ischemic hypothermia on regional cerebral blood flow (rCBF) and infarct volume using a transient focal cerebral ischemia model. Normal temperature was maintained in a group of 7 anesthetized rats, and hypothermia (30 degrees C) was maintained in two other groups of 7 anesthetized rats, in which alpha-stat (PaCO2 measured at 37 degrees C was maintained at 36 mmHg) and pH-stat (PaCO2 corrected for body temperature was maintained at 36 mmHg) conditions, respectively, were established. rCBF was monitored by laser-Doppler flowmetry in the ischemic penumbra. The middle cerebral artery (MCA) was occluded for 2 h and then reperfused. Infarct volume was measured after 24 h and expressed as a percentage of hemisphere volume. Pre-ischemic hypothermia reduced rCBF in the alpha-stat group and the pH-stat group to 52 +/- 2% and 86 +/- 7%, respectively (p < 0.01). After MCA occlusion, rCBF dropped in the control group, alpha-stat group, and pH-stat group to 57 +/- 11%, 31 +/- 9%, 27 +/- 10%, respectively. Infarct volume in the alpha-stat group, and pH-stat group was significantly smaller (10 +/- 1% and 7 +/- 2%) than in the control group (42 +/- 7%, p < 0.01), but no differences were found between the hypothermic groups. Differences in acid-base management in the present study did not affect infarct volume, but pre-ischemic rCBF in the alpha-stat group was significantly lower than in the pH-stat group. The steeper fall in rCBF after MCA occlusion in the pH-stat group suggested that the autoregulatory response of the collateral pathways may have been reduced in this group.

Moderate hypothermia reduces hypotensive, but not hypercapnic vasodilation of pial arterioles in rats.

Two types of acid-base strategies are available for the blood gas management of patients during hypothermia: alpha-stat and pH-stat management. However, the more suitable strategy for therapeutic hypothermia is unclear. We studied the effects of hypothermia (30 degrees C) and acid-base management on reactivity to hypercapnia and hypotension in rat pial arterioles, using a closed cranial window. The baseline diameter during hypothermia decreased in the alpha-stat (PaCO2 was maintained at 35 mm Hg when measured at 37 degrees C, n = 8), but not in the pH-stat (PaCO2 was maintained at 35 mm Hg when corrected to the animal's actual temperature, n = 7). Vasodilation induced by hypotension was significantly reduced in hypothermic groups compared with the normothermic group (n = 7), whereas responses to hypercapnia were preserved. Moreover, hypotensive vasodilation was more attenuated in the pH-stat, than the alpha-stat, management. These findings show that moderate hypothermia and acid-base management alter cerebrovascular autoregulation.

The significance of retrograde thrombosis following removal of arteriovenous malformations in elderly patients.

BACKGROUND: Retrograde thrombosis of former feeding arteries should be considered as a distinct postoperative complication following surgery for arteriovenous malformation (AVM). Regardless of the presence of AVMs, the cerebral arteries undergo atherosclerotic changes with advancing age. In the present study, three cases in elderly patients who developed retrograde thrombosis are reported, and the effect of the patient's age on this complication is discussed. CLINICAL MATERIALS AND METHODS: The present study group consisted of 158 patients who underwent AVM resection and postoperative angiographic studies. Five patients were 65 years of age or older (elderly group) at the time of operation, 108 were between 20 and 64 years of age (adult group), and 45 were less than 20 years of age (young group). The incidence of retrograde thrombosis in the elderly group was compared with that of the other two groups. RESULTS: We found that surgery in the elderly group was accompanied by a significantly higher incidence of retrograde thrombosis (60%) than in the adult group (4%), or the young group (0%). CONCLUSIONS: The present study suggests that this complication should be considered as a serious possibility following removal of an AVM, especially in elderly patients.

A canine model of intracranial arteriovenous shunt with acute cerebral venous hypertension.

Increased pressure of draining veins in intracranial arteriovenous fistula is considered an important cause of clinical symptoms. To investigate hemodynamic changes in intracranial arteriovenous fistula with cerebral venous hypertension, we developed a new canine model of this condition. A lingual artery-superior sagittal sinus (SSS) shunt was constructed using a section of the femoral artery as an interposed graft; immediately after which, monitoring of SSS pressure (SSSP) and regional cerebral blood flow (rCBF) was started. The baseline SSSP was 4.1 +/- 3.7 mmHg. After shunt opening, it increased slightly but not significantly. When the SSS was occluded with a clip with the shunt closed, SSSP rose to 20.3 +/- 9.0 mmHg (p < 0.01). Finally, on shunt opening, with the SSS caudal (downstream) to it occluded, the SSSP increased to 59.5 +/- 22.9 mmHg (p < 0.01, multiple analysis of variance, contrast). The frontal lobe rCBF decreased as the cerebral perfusion pressure (CPP) (mean blood pressure minus SSSP) fell. However, cerebral vascular resistance decreased significantly and proportionately to the reduced CPP (r = 0.66, p < 0.0001). In conclusion, when an intracranial arteriovenous shunt was present, venous outflow obstruction was shown to be necessary for cerebral venous hypertension to occur. In acute venous hypertension, decreases in rCBF occurred, but the autoregulatory vasodilating response was also active.

The efficacy of bypass surgery for the patients with hemorrhagic moyamoya disease.

The efficacy of bypass surgery for the patients with hemorrhagic Moyamoya disease were studied by multi-center retrospective questionnaire study. The rebleeding rate was 28.3% (39/138 patients) in conservative treatment group and 19.1% (29/152 patients) in bypass surgery group with no significant statistical difference. It is still difficult to clarify the efficacy of bypass surgery for prevention of hemorrhagic attack.

Mass effect caused by clinically unruptured cerebral arteriovenous malformations.

OBJECTIVE: It is generally considered that mass effect caused by arteriovenous malformations (AVMs) is evidence of ruptures. In the present study, the incidence of mass effect in clinically unruptured AVMs was evaluated, and the underlying causative factors and pathophysiological mechanisms were studied. METHODS: Twenty-seven patients with clinically unruptured supratentorial pial AVMs were examined. The majority were suffering from epilepsy, and frontal lobe involvement was revealed in approximately half of the patients. Angiographic studies, computed tomographic scans, and magnetic resonance images were obtained for all patients. Twenty-one patients underwent removal of AVMs. In 10 of the surgically treated patients, intraoperative vascular pressure measurements were obtained before removal of the AVMs. RESULTS: Mass effect was detected in 12 (44%) of the 27 patients. Cortical sulci obliteration (eight patients) and lateral ventricle displacement (seven patients) were frequently noted. The volume of AVMs was significantly larger in patients with mass effect than in those without mass effect (P < 0.001). Large dilated venous sacs or ectatic veins were observed to be associated with mass effect (P < 0.001). In only one patient was gross displacement related to a surrounding massive brain edema. Draining vein pressure in patients with mass effect was significantly elevated as compared to the average value in patients without mass effect (22 +/- 5 versus 12 +/- 3 mm Hg) (P < 0.01). CONCLUSION: The present study suggests that mass effect is not infrequent in clinically unruptured AVMs. Furthermore, multiple causative factors were detected, including the large size of AVMs, marked draining vein dilatation, and brain edema around the AVMs. Findings also indicated that a pathophysiologically high pressure in the venous drainage system may contribute to mass effect.

Investigations of the Dose of Heparin and Whole Blood Coagulation Time during Endovascular Surgery.

SUMMARY: We chronologically determined whole blood coagulation time during continuous heparin administration, and investigated optimal doses of heparin in thirty-seven vascular surgery cases. ACT was determined with Hemochron 401. Heparin (2000 IU) was administered by bolus injection at the beginning of intravascular surgery, which was followed by continuous injection of 20 to 160 IU/kg/h. ACT determined before and 30 minutes after heparin administration were compared. There were no complications. ACT was maintained at a nearly constant level by continuous heparin administration. The dose of heparin required to maintain ACT at a level 1.5 to 2 times the initial level was 20 to 60 IU/kg/h. ACT was prolonged by more than three times in two of the ten subjects who were given heparin at a dose of 70 IU/kg/h or more. Continuous administration of heparin allowed maintenance of ACT at a nearly constant level during intravascular surgery. ACT was maintained within the range which is believed to be effective for prevention of thrombus formation (approximately 1.5 to 2.0 times larger than the initial level) by continuous administration of 20 to 60 IU/kg/h of heparin. ACT was, however, prolonged to more than three times the initial level in some subjects who were given 70 IU/kg/h or higher doses, suggesting the risk of a bleeding tendency. Accordingly, it is ideal to continue heparin administration at appropriate doses, while measuring ACT. The results of our study should serve as a useful standard for meeting this goal.

Impaired autoregulation in an experimental model of chronic cerebral hypoperfusion in rats.

BACKGROUND AND PURPOSE: To verify the hypothesis that impaired autoregulation may contribute to cerebral swelling or hemorrhage after a sudden recovery of perfusion pressure, we studied the chronic effects of cerebral hypoperfusion on the autoregulatory responses of the pial arterioles in situ. METHODS: Eight to 12 weeks after a carotid-jugular fistula was created in rats, experiments were performed under alpha-chloralose and urethane anesthesia. Regional cerebral blood flow (rCBF) was determined by the hydrogen clearance method, and carotid pressure was measured. Using a closed cranial window, we determined the autoregulatory responses of the arterioles (30 to 50 microns) to both hypertension induced by norepinephrine and sudden fistula closure at various mean arterial pressures (MAPs). RESULTS: rCBF on the fistula side was reduced by 27%. Carotid pressure was significantly lower than normal but was immediately increased by fistula closure. The pial arterioles showed marked elongation and enlargement. During induced hypertension, the arterioles in the fistula group started to dilate at an MAP lower than that of the control group (130 versus 180 mm Hg, respectively). The arterioles constricted when the fistula was occluded at normal MAP. However, when the fistula was occluded at an MAP higher than 130 mm Hg, the vessels dilated. CONCLUSIONS: It was demonstrated that (1) chronic hypoperfusion induced impairment of the upper limit of autoregulation and (2) sudden fistula closure under hypertensive conditions caused vasodilation of the arterioles. These findings suggest that rapid restoration of perfusion pressure is possibly followed by a pressure breakthrough phenomenon in a chronically hypoperfused cerebrovasculature.

A source of haemorrhage in adult patients with moyamoya disease: the significance of tributaries from the choroidal artery.

This study concerns 19 patients over 16 years of age with Moyamoya disease. Ten cases of intracranial haemorrhage, as the initial haemorrhagic event in patients aged from 21 to 55 (haemorrhagic group) and 9 cases of ischaemic events in 18- to 53-year-old patients (ischaemic group) were included. All haemorrhages were associated with intraventricular haemorrhages (IVH); and all but one case of thalamic haemorrhage were thought to be primary IVH (2 cases of small paraventricular haemorrhage; 2 of small haemorrhages in the splenium; 5 with no intracerebral haematoma). In the 9 patients of the ischaemic group, there were 2 cases of transient ischaemic attacks and 7 of cerebral infarction. Angiographic evaluations demonstrated that the abnormal basal vessel formation and the collateral supplies from the external carotid arteries were poorly developed in both groups. In contrast, the collateral circulation via the choroidal and posterior pericallosal arteries was well demonstrated. Furthermore, marked enlargement of the choroidal arteries and the medullary arteries derived from them was seen more frequently in the haemorrhagic group. These findings suggested that the haemodynamic load in the vessels supplying the walls of the posterior parts of the ventricles and the periventricular region was increased, especially in the haemorrhagic group. Those vessels were considered to be important sites of IVH in adult patients with Moyamoya disease.

The effects of a carotid-jugular fistula on cerebral blood flow in the cat: an experimental study in the chronic period.

The purpose of the present study was to investigate the effects of feline carotid-jugular fistula (Spetzler's model) on cerebral blood flow at 8 weeks after creation of the fistula. Using laser-Doppler flowmetry, cortical cerebral blood flow (CBF) on the fistula side was measured in 10 cats, Occlusion of the fistula showed no cortical CBF changes in 6 animals, but transient increases in 4. CO2 reactivity in the closed fistula was preserved. No neurological or histological abnormalities were recognized. These findings suggested that cerebral hemodynamic changes due to Spetzler's CJ fistula model are minimal even in the chronic period after fistulization. Therefore, creation of another experimental arterio-venous fistula model is mandatory for the investigation of hemodynamic changes following resection of a cerebral arteriovenous malformation.

Cerebrovascular alterations in mice lacking neuronal nitric oxide synthase gene expression.

Nitric oxide (NO) is known to mediate increases in regional cerebral blood flow elicited by CO2 inhalation. In mice with deletion of the gene for neuronal NO synthase (NOS), CO2 inhalation augments cerebral blood flow to the same extent as in wild-type mice. However, unlike wild-type mice, the increased flow in mutants is not blocked by the NOS inhibition, N omega-nitro-L-arginine, and CO2 exposure fails to increase brain levels of cGMP. Topical acetylcholine elicits vasodilation in the mutants which is blocked by N omega-nitro-L-arginine, indicating normal functioning of endothelial NOS. Moreover, immunohistochemical staining for endothelial NOS is normal in the mutants. Thus, following loss of neuronal NOS, the cerebral circulatory response is maintained by a compensatory system not involving NO.

Cerebrovascular responses under controlled and monitored physiological conditions in the anesthetized mouse.

Control of physiological parameters such as respiration, blood pressure, and arterial blood gases has been difficult in the mouse due to the lack of technology required to monitor these parameters in small animals. Here we report that anesthetized and artificially ventilated mice can be maintained under physiological control for several hours with apparently normal cerebrovascular reactivity to hypercapnia and mechanical vibrissal stimulation. SV-129 mice were anesthetized with urethane (750 mg/kg i.p.) and alpha-chloralose (50 mg/kg i.p.), intubated, paralyzed, and artificially ventilated. Respiratory control was maintained within physiological range by reducing the inspiratory phase of the respiratory cycle to < 0.1 s and by adjusting end-tidal CO2 to give a PCO2 of 35 +/- 3 mm Hg. In these mice, mean arterial pressure (95 +/- 9 mm Hg), heart rate (545 +/- 78 beats/min), and arterial pH (7.27 +/- 0.10) could be maintained for several hours. Body temperature was kept at 36.5-37.5 degrees C. We observed stable regional CBF (rCBF) measurements (as determined by laser-Doppler flowmetry) when systemic arterial blood pressure was varied between 40 and 130 mm Hg. Hypercapnia led to a 38 +/- 15% (5% CO2) and 77 +/- 34% (10% CO2) increase in rCBF. Mechanical stimulation of contralateral vibrissae for 1 min increased rCBF by 14 +/- 4%. Changes in rCBF compare favorably with those observed previously in another rodent species, the Sprague-Dawley rat. After placement of a closed cranial window, cerebrovascular reactivity to hypercapnia and whisker stimulation was intact and well maintained during 2-h superfusion with artificial CSF.