Adding diet and exercise counseling to the health promotion plan alleviates anthropometric and metabolic complications in patients with metabolic syndrome.

We investigated the effects of individual (IC) and group (GC) diet and exercise counseling in men with metabolic syndrome. Participants received exercise instruction and exercise load was monitored. IC participants received individual diet counseling sessions and general consultations at baseline and monthly. GC participants received a group diet counseling session at baseline and general consultations at baseline and monthly. In the IC group, body mass index (BMI) percent body fat, waist circumference, diastolic blood pressure, low-density lipoprotein cholesterol, glycosylated hemoglobin A1c, and liver function levels were reduced significantly after 3 months, whereas in the GC group, waist circumference and levels of liver function were reduced. Exercise load was negatively correlated with change in BMI and waist circumference in the IC group, and positively correlated with changes in high-density lipoprotein cholesterol levels in all subjects and in the GC group. Diet and exercise counseling, especially IC, may benefit patients with metabolic syndrome.

[Graft replacement for surgical repair of coarctation of the aorta in adults].

We report the graft replacement for surgical repair of coarctation of the aorta (CoA) in 2 men, aged 19 and 30 years old, respectively. In both patients, the pressure gradients were higher than 20 mmHg across the coarctaion by cathetherization, and higher than 30 mmHg between the upper and lower limbs. The graft replacement of the coarctated aorta was performed under cardiopulmonary bypass. Postoperatively, the pressure gradients between the upper and lower limbs dropped below 20 mmHg in both cases. Since about 50% of surgically untreated patients with this disease may be expected to die before 30 years of age, repair of CoA in adults should be performed as soon as possible.

Caloric restriction, aerobic exercise training and soluble lectin-like oxidized LDL receptor-1 levels in overweight and obese post-menopausal women.

BACKGROUND: Elevated circulating levels of soluble lectin-like oxidized low-density lipoprotein receptor-1 (sLOX-1) have been observed in obese persons and are reduced by weight loss. However, it is not known whether combining caloric restriction (CR) with exercise training is better in reducing sLOX-1 levels than CR alone. OBJECTIVE: We examined whether the addition of aerobic exercise to a weight loss intervention differentially affects sLOX-1 levels in 61 abdominally obese post-menopausal women randomly assigned to a CR only (n = 22), CR+moderate-intensity exercise (n = 22) or CR+vigorous-intensity exercise (n = 17) intervention for 20 weeks. The caloric deficit was ~2800 kcal per week for all groups. RESULTS: The intervention groups were similar at baseline with respect to body weight, body composition, lipids and blood pressure. However, plasma sLOX-1 levels were higher in the CR-only group (99.90 ± 8.23 pg ml(-1)) compared with both the CR+moderate-intensity exercise (69.39 ± 8.23 pg ml(-1), P = 0.01) and the CR+vigorous-intensity exercise (72.83 ± 9.36 pg ml(-1), P = 0.03) groups. All three interventions significantly reduced body weight (~14%), body fat and waist and hip circumferences to a similar degree. These changes were accompanied by a 23% reduction in sLOX-1 levels overall (-19.00 ± 30.08 pg ml(-1), P < 0.0001), which did not differ among intervention groups (P = 0.13). Changes in body weight, body fat and maximal oxygen consumption (VO(2) max) were not correlated with changes in sLOX-1 levels. In multiple regression analyses in all women combined, baseline sLOX-1 levels (ß = -0.70 ± 0.06, P < 0.0001), age (ß = 0.92 ± 0.43, P = 0.03) and baseline body mass index (BMI) (ß = 1.88 ± 0.66, P = 0.006) were independent predictors of the change in sLOX-1 with weight loss. CONCLUSIONS: Weight loss interventions of equal energy deficit have similar effects on sLOX-1 levels in overweight and obese post-menopausal women, with the addition of aerobic exercise having no added benefit when performed in conjunction with CR.

[Dissecting aneurysms at the bases of the brachiocephalic artery and the left common carotid artery due to localized dissection of the aortic arch; report of a case].

A 43-year-old male lost consciousness immediately after archery practice, and was brought to our hospital by ambulance. Angiography showed dissecting aneurysms at the bases of the brachiocephalic artery and the left common carotid artery, causing compression of these arteries. Under cardiopulmonary bypass with selective cerebral perfusion, the blood supply to these arteries was restored with a bifurcated graft. Surgical specimen showed localized dissection of the aortic arch at the bifurcation to the brachiocephalic artery and the left common carotid artery, with the formation of dissecting aneurysms at the bases of both arteries. The aneurysms were filled with thrombi. In addition to these dissecting aneurysms, there were arterial dissections involving the brachiocephalic artery and the bilateral common carotid arteries. Histopathological examination of the vessel wall showed no evidence of atherosclerosis or vasculitis, and no abnormalities in the arrangement of elastic fibers.

Intraoperative monitoring of penile and buttock blood flow during endovascular abdominal aortic aneurysm repair.

OBJECTIVE: The purpose of this study was to assess the pelvic circulation during endovascular abdominal aortic aneurysm repair (EVAR) with a new monitoring system measuring penile and buttock blood flow. METHODS: We measured penile brachial pressure index (PBI) during EVAR by pulse-volume-plethysmography (form PWV/ABItrade mark). We also measured bilateral gluteal tissue oxygen metabolism with near-infrared spectroscopy to provide a gluteal tissue oxygenation index (TOI). Twenty-two men who underwent aortouni-iliac stentgraft with crossover bypass for exclusion of abdominal aortic aneurysm were studied. Twelve patients underwent aorto-uni-common iliac artery stentgraft (CIA) and ten underwent aorto-uni-external iliac artery stentgraft (EIA). RESULTS: In all patients, there was an immediate reduction in PBI during the EVAR procedure. After revascularization of the ipsilateral limb of the stent graft, the recovery of PBI was significantly less in EIA group. After the completion of crossover bypass, PBI in both groups recovered to the baseline values. In both groups there was a bilateral reduction in gluteal TOI during malperfusion of the internal iliac artery. After revascularization of ipsilateral limb of the stent graft, the ipsilateral TOI recovered to the baseline level in CIA patients, but recovery was incomplete in EIA patients. In contrast, contra-lateral TOI remained low in both groups after revascularization of ipsilateral limb of the stent graft. Only after completion of crossover bypass did the contra-lateral TOI recover to baseline level in both groups. CONCLUSIONS: Both TOI at the buttocks and PBI are a sensitive reflection of pelvic haemodynamics. Penile blood flow and bilateral gluteal blood flow are supplied via different circulations and both should be monitored for full assessment of the pelvic circulation.

Intracranial cerebrospinal fluid measurement studies in suspected idiopathic normal pressure hydrocephalus, secondary normal pressure hydrocephalus, and brain atrophy.

OBJECTIVE: To investigate intracranial cerebrospinal fluid (CSF) distribution in patients with a clinical diagnosis of idiopathic normal pressure hydrocephalus (INPH). METHODS: 24 patients with a clinical diagnosis of INPH were studied. Control groups comprised 17 patients with secondary normal pressure hydrocephalus (SNPH), 21 patients with brain atrophy, and 18 healthy volunteers. Ventricular volume (VV) and intracranial CSF volume (ICV) were measured using a magnetic resonance based method and the VV/ICV ratio was calculated. RESULTS: The SNPH group showed a marked increase in the VV/ICV ratio compared with the healthy volunteers (37.8% v 15.6%, p < 0.0001). The brain atrophy group showed a significant increase in ICV compared with the healthy volunteers (284.4 ml v 194.7 ml, p =0.0002). The INPH group showed an increase in ICV (281.2 ml, p = 0.0002) and an increase in the VV/ICV ratio (38.0%, p < 0.0001). Fifteen of 24 INPH patients underwent shunting; 11 improved and four did not. CONCLUSIONS: The results suggest that INPH patients have brain atrophy in addition to hydrocephalic features. This may help to explain the difficulties encountered in the diagnosis and the unpredictable response rate to shunt surgery in INPH patients.

Intracranial cerebrospinal fluid distribution and its postoperative changes in normal pressure hydrocephalus.

BACKGROUND: This study was conducted to investigate the usefulness of intracranial cerebrospinal fluid (CSF) volume measurement using MR-based methods in the management of patients with normal pressure hydrocephalus (NPH). METHODS: The study group comprised 19 patients with NPH who showed a favorable outcome after ventricular shunting, 15 normal volunteers (NV), and 15 patients with cerebrovascular disease (CVD). A 3D-fast asymmetric spin echo MR imaging sequence and the region-growing method were used to extract the CSF space from MR images. Ventricular volume (VV) and intracranial CSF volume (ICV) were measured and the VV/ICV ratio was calculated in each case. In NPH patients, the CSF volume was measured again after shunting. FINDINGS: The mean VV and VV/ICV ratio in the NPH group (91.1 mL and 45.2%, respectively) were significantly (p < 0.01) higher than those in the NV group (26.5 mL and 13.7%) and in the CVD group (44.5 mL and 17.8%). On the other hand, mean ICV values were not significantly different among the three groups. The VV was markedly decreased postoperatively (mean -40.7%), whereas the ICV was unchanged, resulting in a marked reduction in the VV/ICV ratio (mean -39.3%). INTERPRETATION: These results suggest that patients with NPH have a unique intracranial CSF distribution, with an enlarged VV and a slightly increased ICV, resulting in a high VV/ICV ratio. Shunting led to dramatic improvement in our patients. It is likely that CSF measurement can provide valuable information in the management of patients with NPH.

Peritoneal lavage with oxygenated perfluorochemical preserves intestinal mucosal barrier function after ischemia-reperfusion and ameliorates lung injury.

OBJECTIVE: To evaluate the effect of peritoneal lavage with an oxygenated perfluorochemical (PFC) on intestinal ischemia-reperfusion injury (IIR), we assessed intestinal barrier function in terms of bacterial translocation and endotoxemia, morphologic changes, and changes of intestinal luminal pH in rats subjected to IIR. We also examined lung injury after IIR to test the effect of oxygenated PFC lavage on remote organ failure. DESIGN: Prospective, randomized, and controlled animal study. SETTING: Laboratory of a university hospital. SUBJECT: Male Sprague-Dawley rats. INTERVENTIONS: Rats were subjected to ischemia by clipping the superior mesenteric artery. Reperfusion was achieved by release of the clip. Lavage of the abdominal cavity was performed by inflow and outflow of oxygenated PFC solution during ischemia. RESULTS: Rats undergoing peritoneal lavage with oxygenated PFC (PFC group) showed significantly better survival after IIR. The frequency of bacterial translocation and the endotoxin concentration in superior mesenteric venous blood were significantly lower in the PFC group. Luminal acidosis also was alleviated in the PFC group. Furthermore, PFC lavage preserved the intestinal mucosal architecture and inhibited interstitial edema and infiltration of inflammatory cells in the lungs. CONCLUSION: We conclude that peritoneal lavage with oxygenated PFC protects the intestinal mucosa and maintains mucosal barrier function after IIR. Preservation of the intestinal mucosa ameliorates lung injury after IIR.

Pancreatic enzymes and microvascular cell activation in multiorgan failure.

Cell activation in the microcirculation leads to an inflammatory cascade and is accompanied by many cardiovascular complications. There is a need to identify the trigger mechanisms that lead to the production of in vivo activating factors. We review here mechanisms for cell activation in the microcirculation and specifically the production of humoral cell activators in physiological shock. The elevated levels of activating factors in plasma could be traced to the action of pancreatic enzymes in the ischemic intestine. New interventions against the production of the activators are proposed. The evidence suggests that pancreatic enzymes in the ischemic intestine may attack several tissue components and generate cellular activators that are associated with multiorgan dysfunction in physiological shock.

Mechanisms for blockade of in vivo activator production in the ischemic intestine and multi-organ failure.

Our recent results indicate that pancreatic enzymes in the ischemic intestine are involved in the production of in vivo activators, which stimulate cells in the cardiovascular system and initiate multiple organ failure. Since the intestine is a rich source of xanthine oxidase (XO), we investigated whether XO may be involved in the production of circulating activators in shock. The small intestine was perfused with saline (SAL group), a broad acting pancreatic enzyme inhibitor, ANGD (ANGD group), allopurinol (ALLOP group), or a combination of ANGD and allopurinol (ANGD + ALLOP group). 100 min of splanchnic arterial occlusion was followed by 120 min of reperfusion. Leukocytes from asymptomatic volunteers were incubated with plasma from experimental animals, and the fractions of pseudopod positive cells were counted as an indicator for the activator. ANGD served to preserve the arterial blood pressure (MAP) close to its control values (96.6 +/- 6.2 % in ANGD versus 60.9 +/- 6.2 % in SAL, 120 min after reperfusion, P < 0.05). In line with our previous experiments, ANGD decreased the formation of activator (30.5 +/- 4.8% in SAL versus 7.3 +/- 1.6 % in ANGD, 120 min after reperfusion, P< 0.05). Although allopurinol inhibited the XO in the small intestine, no protection from early indicators of multi-organ injury was detected. The recovery of MAP and reduced levels of plasma activator achieved in the ANGD + ANGD group was similar to those in the ALLOP group. These results indicate that XO may not serve as a significant source for plasma derived activators in an acute phase of shock after severe intestinal ischemia.

A quantitative index of intracranial cerebrospinal fluid distribution in normal pressure hydrocephalus using an MRI-based processing technique.

Our purpose was to quantify the intracranial cerebrospinal fluid (CSF) volume components using an original MRI-based segmentation technique and to investigate whether a CSF volume index is useful for diagnosis of normal pressure hydrocephalus (NPH). We studied 59 subjects: 16 patients with NPH, 14 young and 13 elderly normal volunteers, and 16 patients with cerebrovascular disease. Images were acquired on a 1.5-T system, using a 3D-fast asymmetrical spin-echo (FASE) method. A region-growing method (RGM) was used to extract the CSF spaces from the FASE images. Ventricular volume (VV) and intracranial CSF volume (ICV) were measured, and a VV/ICV ratio was calculated. Mean VV and VV/ICV ratio were higher in the NPH group than in the other groups, and the differences were statistically significant, whereas the mean ICV value in the NPH group was not significantly increased. Of the 16 patients in the NPH group, 13 had VV/ICV ratios above 30%. In contrast, no subject in the other groups had a VV/ICV ratios higher than 30%. We conclude that these CSF volume parameters, especially the VV/ICV ratio, are useful for the diagnosis of NPH.

Ultrasonography improves diagnostic accuracy of acute appendicitis and provides cost savings to hospitals in Japan.

A cost analysis based on changes in patient care was used to evaluate the utility of abdominal ultrasonography in both the clinical management of patients clinically suspected of having acute appendicitis and in reducing expenditure of hospital resources. Among the 200 patients suspected of having acute appendicitis, 57 actually had acute appendicitis. Interpretation of appendiceal ultrasonographic results was 98.5% accurate. The ultrasonographic result led to changes in the treatment of 103 patients. Moreover, ultrasonography led to the prevention of unnecessary appendectomy in 25 patients, providing a savings to the hospital of about Yen 8,013,450 ($65,150), and prevented unnecessary hospital admission for 78 patient-days, thus saving the hospital approximately Yen 1,199,250 ($9750). The cost of performing the 200 ultrasonographic examinations was about Yen 1,096,176 ($8912), and thus the overall savings to the hospital was approximately Yen 40,590 ($330) per patient. Ultrasonography performed in patients with suspected acute appendicitis improves patient diagnostic accuracy, thus leading to more appropriate selection of patient treatment and reduced hospital expenditure.

Generation of in vivo activating factors in the ischemic intestine by pancreatic enzymes.

One of the early events in physiological shock is the generation of activators for leukocytes, endothelial cells, and other cells in the cardiovascular system. The mechanism by which these activators are produced has remained unresolved. We examine here the hypothesis that pancreatic digestive enzymes in the ischemic intestine may be involved in the generation of activators during intestinal ischemia. The lumen of the small intestine of rats was continuously perfused with saline containing a broadly acting pancreatic enzyme inhibitor (6-amidino-2-naphthyl p-guanidinobenzoate dimethanesulfate, 0.37 mM) before and during ischemia of the small intestine by splanchnic artery occlusion. This procedure inhibited activation of circulating leukocytes during occlusion and reperfusion. It also prevented the appearance of activators in portal venous and systemic artery plasma and attenuated initiating symptoms of multiple organ injury in shock. Intestinal tissue produces only low levels of activators in the absence of pancreatic enzymes, whereas in the presence of enzymes, activators are produced in a concentration- and time-dependent fashion. The results indicate that pancreatic digestive enzymes in the ischemic intestine serve as an important source for cell activation and inflammation, as well as multiple organ failure.

Pathophysiological role of endothelins in pulmonary microcirculatory disorders due to intestinal ischemia and reperfusion.

BACKGROUND: This study was conducted to investigate pulmonary microcirculatory disorders caused by intestinal ischemia reperfusion (IIR), and the pathophysiological roles of endothelin (ET) in acute lung injury (ALI). METHODS: Male rats were pretreated with normal saline or a nonselective ET receptor antagonist (TAK-044) and subjected to IIR (60 min of intestinal ischemia and 180 min of reperfusion). The right upper lobe of the lung was examined by intravital confocal microscopy. RESULTS: The size of arterioles and venules was not significantly reduced during IIR, but the functional capillary density (FCD) decreased significantly. TAK-044 improved the pulmonary microhemodynamics, inhibiting the accumulation of leukocytes, the pulmonary edema, and the decrease of FCD. CONCLUSIONS: In the early stage of IIR, pulmonary microhemodynamics seemed more likely to be disturbed by the decrease of FCD, than by arteriolar or venular vasoconstriction. ETs decrease the FCD, promoting the interaction between leukocytes and pulmonary vessels.

Intravital laser confocal microscopy of pulmonary edema resulting from intestinal ischemia-reperfusion injury in the rat.

OBJECTIVE: To observe pulmonary edema resulting from intestinal ischemia-reperfusion injury. We used a newly developed laser confocal microscope to observe the subpleural capillary network and the superficial alveoli under intravital conditions, and created three-dimensional images of the pulmonary microcirculation to analyze the time course and spatial pattern of pulmonary exudative changes during intestinal ischemia-reperfusion injury in vivo. DESIGN: Prospective, randomized, unblinded study. SETTING: Laboratory of a university hospital. SUBJECTS: Male Sprague-Dawley rats. INTERVENTIONS: The rats were injected intravenously with bovine serum albumin labeled with fluorescein isothiocyanate and subjected to 60 mins of intestinal ischemia, followed by 180 mins of reperfusion. During mechanical ventilation, the upper lobe of the right lung was examined in the intravital state using a high-speed confocal fluorescence microscope. MEASUREMENTS AND MAIN RESULTS: Interstitial edema and alveolar leakage were recognized as changes of interstitial fluorescence in the subpleural capillary network and as changes of alveolar fluorescence in the alveolar cross-sectional view. Although exudative changes in the interstitium and alveoli were observed during intestinal ischemia, there was a marked increase in both interstitial edema and alveolar leakage after intestinal reperfusion. CONCLUSION: We observed pulmonary edema under intravital conditions and demonstrated the utility of a newly developed laser confocal microscope. This system not only enabled us to analyze the development of pulmonary edema three-dimensionally, but also allowed us to evaluate the pulmonary microcirculation.

Microanatomy of the cerebellopontine angle and internal auditory canal: study with new magnetic resonance imaging technique using three-dimensional fast spin echo.

OBJECTIVE: We report a new magnetic resonance imaging technique that uses three-dimensional fast spin echo and the minimum intensity projection method. Using this technique, detailed images of the cerebellopontine angle (CPA) and internal auditory canal (IAC) were obtained in normal volunteers and in patients with acoustic neuromas or hemifacial spasm. METHODS: Ten normal volunteers, 44 patients with acoustic neuromas, and 31 patients with hemifacial spasm were studied using the three-dimensional fast spin echo magnetic resonance imaging protocol. The CPA and IAC were scanned by using a 1-mm slice thickness in the axial and parasagittal planes. RESULTS: Normal anatomy was as follows. 1) The vestibulocochlear nerve was ovoid near the brain stem and changed to a slightly crescentic configuration (C shape) as it traveled laterally. 2) Separation of the cochlear and vestibular nerves was observed near the central part of the IAC. 3) Discrimination between the superior and inferior vestibular nerves was also possible near the fundus of the IAC. 4) The facial nerve was easily identifiable as a discrete nerve at the anterior aspect of the vestibulocochlear nerve. 5) The meatal loop of the cerebellar artery was located medial to the porus in 44% of 95 CPAs and reached the porus or protruded into the porus in 56%. Acoustic neuromas were as follows. 1) In a patient with a very small intracanalicular tumor, the nerve on which the tumor was located could be identified. 2) In 22 of 44 acoustic neuromas, cerebrospinal fluid was present between the tumor and the fundus of the IAC. Hemifacial spasm was as follows. The relationship between the responsible artery and the facial nerve could be precisely observed. CONCLUSION: The three-dimensional fast spin echo method offers ultrahigh-resolution images, which are extremely useful in understanding the surgical anatomy of the CPA and IAC.

Contribution of endothelin-1 to microcirculatory impairment in total hepatic ischemia and reperfusion injury.

BACKGROUND: Endothelin (ET)-1 may have a role in hepatic polymorphonuclear leukocyte infiltration as well as microcirculatory disturbance during hepatic ischemia-reperfusion (HIR) injury. This study was conducted to investigate the influence of ET-1 on the hepatic microcirculation after total HIR and to evaluate the effect of a nonselective ET receptor antagonist under these conditions. METHODS: Male rats pretreated with either normal saline (NS group) or TAK-044, a nonselective ET receptor antagonist (TAK group), were subjected to 120 min of total hepatic ischemia with extracorporeal portosystemic shunting. RESULTS: Plasma ET-1 levels increased significantly from 1 to 6 hr after reperfusion in the NS group when compared with the nonischemic control. In the early phase of reperfusion, the NS group showed significantly narrower sinusoids, lower hepatic tissue blood flow, a lower hepatic tissue oxy-hemoglobin concentration, and more hepatic neutrophil infiltration than the TAK group (P<0.05). Pretreatment with TAK-044 improved hepatic microcirculatory derangement, and resulted in significantly better 7-day survival (61.5%) with more bile production after reperfusion when compared with the NS group (P<0.01). CONCLUSIONS: The present study demonstrated that ET-1 is involved in the development of HIR injury by causing deterioration of the hepatic microcirculation. A nonselective ET receptor antagonist successfully ameliorated HIR injury through improvement of hepatic oxygenation and of the microcirculation along with reduced hepatic neutrophil infiltration.

Pathophysiological appraisal of a rat model of total hepatic ischemia with an extracorporeal portosystemic shunt.

BACKGROUND: Animal models of total hepatic ischemia (THI) and reperfusion injury are restricted by concomitant splanchnic congestion. This study was performed to determine the requirement suitable for an extracorporeal portosystemic shunt (PSS) to maintain the intestinal integrity in a rat model of THI. MATERIALS AND METHODS: Using a polyethylene tube (0.86 or 1 mm i.d.), PSS was placed between the mesenteric and jugular veins. Comparison was done between THI models with or without PSS and a partial ischemia model with hepatectomy of the nonischemic lobes. Well-tolerated hepatic ischemic period, portal pressure after 10 min of hepatic ischemia, portal endotoxin levels at 1 h after reperfusion, histological features of the small bowel just before reperfusion, and local jejunal and ileal blood hemoglobin oxygen saturation index (ISO2) were compared among the models. RESULTS: Animals without PSS poorly tolerated 30 min of THI. Animals receiving THI with PSS or partial hepatic ischemia tolerated a longer ischemic period (60 min) with a significantly higher small bowel ISO2, lower portal pressure and endotoxin levels (P < 0.01), and less histological damage of the small bowel when compared to those receiving THI without PSS. Portal endotoxin levels after THI with PSS using a 1-mm i.d. tube as well as partial hepatic ischemia were significantly lower than those after THI with PSS using a 0.86-mm i.d. tube. CONCLUSIONS: THI with PSS using a 1-mm i.d. tube was strikingly similar to partial hepatic ischemia in the pathophysiological profile during hepatic ischemia. PSS with a tube 1 mm or more in inner diameter offers pathophysiological advantages in experiments on THI and reperfusion.

Delineation of small nerves and blood vessels with three-dimensional fast spin-echo MR imaging: comparison of presurgical and surgical findings in patients with hemifacial spasm.

BACKGROUND AND PURPOSE: We applied a 3D fast spin-echo (3D-FSE) MR imaging technique to the preoperative and postoperative evaluation of patients with hemifacial spasm. METHODS: The study group comprised 20 patients. All images were acquired on a 1.5-T MR system with a 3D-FSE sequence. RESULTS: In all 20 patients, the courses of the seventh and eighth cranial nerves were depicted separately, and the arteries presumed to be responsible for the hemifacial spasm were seen to be in contact with the facial nerves at the root exit zone (REZ). Eight patients underwent neurovascular decompression. In all patients, the presumed responsible blood vessels depicted by 3D-FSE MR imaging corresponded to intraoperative findings. In addition, postoperative 3D-FSE images confirmed the separation of the facial nerve from a contiguous vessel at the REZ. DISCUSSION: The 3D-FSE technique makes it possible to obtain extremely high-quality images of microstructures in the cerebellopontine cistern, and it has several advantages over conventional angiography: it is noninvasive and able to depict the cranial nerves and surrounding vessels in the same image without contrast material, and it may be useful for postoperative evaluation of the decompression procedure. This imaging technique is expected to prove useful for the clinical evaluation of hemifacial spasm.

[A 29-year-old man with diabetes insipidus and cerebellar ataxia and development of spinal cord swelling 15 years after the onset].

We report a 29-year-old man with diabetes insipidus and cerebellar ataxia who developed spinal cord swelling 15 years after the onset. He was well until 14 years of the age when he noted dizziness. Two years after there was an onset of gait disturbance and slurred speech. He also noted polydipsia and polyuria. He was evaluated at the neurosurgery service of our hospital when he was 17 years of the age. Neurologic examination at that time revealed memory loss, horizontal nystagmus, cerebellar ataxic gait, dysmetria and decomposition more on the left. Cranial CT scan revealed a mass lesion involving the left subthalamic region and the head of the caudate area. Spinal fluid was unremarkable, however, human chorionic gonadotropin was increased to 27 mIU/ml. He was treated by radiation therapy (3,000 rads for total brain area and 5,460 rads for focal region). His CT scan and memory loss improved, however, cerebellar ataxia was unchanged. Three years after the radiation, he started to show choreic movement in his neck and left upper extremity. He was admitted to our service in August 14, 1995 when he was 29 years of the age. On admission, he was alert but disoriented to time; calculation was also poor. Higher cerebral functions were intact. The optic fundi were normal without papilledema. Visual field appeared intact. Gaze nystagmus was observed in all the directions, but more prominent in the horizontal direction. Speech was slurred. Otherwise, cranial nerves were unremarkable. Motor wise, he showed marked truncal and gait ataxia; he was unable to walk because of ataxia. Muscle atrophy and marked weakness was noted in both upper extremities more on the left side. Deep tendon reflexes were diminished in the upper extremities but active in the lower extremities. He was polyuric; urinary specific gravity was low. Spinal fluid contained 6 cells/cmm and 113 mg/ dl of protein; Queckenstedt was positive. MRI revealed swelling of the cervical cord; in addition, the entire cervical region and the medullar oblongata appeared as high signal intensity areas. No mass lesion was noted in the supratentorial structures but the third ventricle was markedly enlarged. Surgical biopsy was performed on the cervical lesion. The patient was discussed in neurologic CPC, and the chief discussant arrived at the conclusion that the patient had germinoma with syncytiotrophoblastic giant cells in the diencephalic region which appeared to have been cured by radiation therapy; he thought that the cervical lesion was the seeding of germinoma. Cerebellar ataxia was ascribed to the remote effect of germinoma. Most of the participants thought that the original tumor was germinoma and the cervical lesion was its spread. Some participants thought that his ataxia was caused by germinoma cells involving the medulla and the inferior cerebellar peduncles. Histologic observation of the biopsied tissue from the spinal cord revealed the typical two cell patterned germinoma. Most of the tumor cells were not stained for an antibody against HCG, but some tumor cells were positively stained. Germinoma is very radio-sensitive; this patient showed T2 high signal lesion involving the medulla oblongata and cervical cord continuously. Probably, tumor cells in the lower brain stem escaped radiation, and gradually spread to the spinal cord over many years. At the time of operation, the surface of the spinal cord was free from tumor cells. Therefore, tumor cells invaded the spinal cord continuously from the medulla oblongata. He was treated with cervical radiation, and his neurologic as well as radiologic findings showed marked improvement.