Transarterial intravenous coil embolization of dural arteriovenous fistula involving the superior sagittal sinus.

BACKGROUND: We report a rare case of traumatic dural arteriovenous fistula involving the superior sagittal sinus successfully treated by transarterial intravenous coil embolization. CASE PRESENTATION: A 38-year-old woman presented with tension headache. She had a past history of severe head injury at the age of three. Computed tomography scanning showed a heterogenous low-density area in the right frontal lobe, and magnetic resonance imaging demonstrated abnormal vascular structures in the same area. Angiography revealed a dural arteriovenous fistula involving the lateral wall of the fully patent superior sagittal sinus. The fistula was fed by scalp, meningeal, and cortical arteries, and drained into a cortical vein leading to the superior sagittal sinus. Femoral transarterial intravenous embolization with microcoils completely occluded the dural arteriovenous fistula. CONCLUSION: Severe head injury may lead to asymptomatic dural arteriovenous fistulas after a long time. Transarterial intravenous coil embolization can be effective in the treatment of dural arteriovenous fistulas involving the superior sagittal sinus.

Measurement of the intracranial arterial wedge pressure in cases of acute cerebral arterial occlusion to determine the indication of intraarterial thrombolytic therapy.

SUMMARY: Wedge pressure of the occluded major cerebral artery (distal pressure beyond the occlusion) was measured to estimate the residual cerebral blood flow in thirteen patients with acute ischemic stroke. There existed the relationship that patients with higher wedge pressure tolerated longer ischemic insults than those with lower wedge pressure. Wedge pressure is measured with minimum time loss before starting thrombolytic therapy and may be a good indicator to estimate the brain tissue reversibility.

Endovascular Surgery for Internal Carotid Stenoses. Results of PTA vs. Stenting.

SUMMARY: This paper will overview our results of endovascular therapy (PTA or stenting) for cervical ICA stenosis and discuss the advantages and disadvantages of each treatment. 60 cases with 62 lesions were treated with PTA 68 times, while 36 cases with 37 lesions were treated with stenting 37 times. A total of 99 lesions were treated with PTA or stenting 105 times. In the PTA group arterial stenosis improved from 76.4% to 21%. In the stent group the stenosis improved from 82.3% to 8.3%. The morbidity rate was 2/60 (3.3%) in PTA group, although two cases had minor neurological deficits, while in stent treated group, morbidity rate was 1/36 (2.8%), although it showed one major neurological deficit. Mortality was 0% in each group. The restenosis rate in PTA group was 15/58 (26%), while it was 0/20 (0%) in stent treated group. Stenting brings significant reduction of stenosis and reduces the rate of restenosis compared to PTA. However, stenting has its own disadvantages such as hypotension and distal kinks when deployed in tortuous ICA stenosis.

Endovascular treatment for internal carotid stenoses. long-term follow-up results and overall complications.

Seventy four cases of internal carotid stenoses greater than 60% were treated by PTA and/or stenting 86 times. Sixty one cases of cervical ICA stenosis were treated 71 times. 11 cases of high cervical - intracranial ICA stenosis were treated 13 times. Two cases of ICA dissection were treated by stent deployment. Stenotic ratio reduced from 79% to 29% in cervical ICA stenosis and 71 % to 32% in high cervical to intracranial ICA stenosis in average. Morbidity related to PTA and/or stenting was 2/74 (2.7%) and mortality was 0%. One was an ischemic complication and the other was a hemorrhagic complication due to hyperper fusion. Restenosis (stenosis greater than 70%) rate was 32%. Asymptomatic cerebral embolism were found in three cases (4.2%) on angiogram immediately after PTA and/or stenting. The complication rate related to PTA and/stenting was low but asymptomatic emboli were found in three cases. Considering these results, the indication for PTA and/stenting should be restricted to patients with high risk group, such as cases with high medical risks or difficult CEA cases, if appropriate protective systems for cerebral emboli were not available.

[When do strokes occur?--analysis of diurnal variation and activity during the onset].

The diurnal variation and activity during the onset of stroke were examined in more than 700 consecutive patients. 304 cases with hypertensive intracerebral hemorrhage (HIH), 214 cases with subarachnoid hemorrhage (SAH) and 201 cases with obstructive cerebrovascular disease (OCVD) were investigated about the time of onset. Concerning the activity during the onset, 296 cases with HIH, 215 cases with SAH and 198 cases with OCVD were examined. HIH occurred frequently between 1500-1800 hours, 0600-0900 hours and 1800-2100 hours. SAH occurred frequently between 0900-1200 hours, 1500-1800 hours and 1800-2100 hours. Both HIH and SAH were least likely to occur between 0000-0300 hours. OCVD exhibited a small peak incidence between 0900-1200 hours, but there were no differences between the groups for the other time periods. Both HIH and SAH were likely to occur frequently in the lavatory, while bathing and during meals. HIH also occurred frequently during physical work, while SAH occurred as frequently during mental work or housework as during hard physical labor. OCVD commonly occurred during sleep or relaxation. The relationship between diurnal variation in stroke and the circadian variation of blood pressure is discussed. The incidence of all three types of strokes during work was higher in the non-aged group (patients under 66 years) than in the aged group (patients over 66 years). HIH and SAH occurred associated with alcohol consumption more frequently in the non-aged group than in the aged group. It is likely that the difference of the time and of the activity during the onset between aged group and non-aged group reflects the difference of life-style between aged and non-aged people.

Percutaneous transluminal angioplasty for intracranial arteriosclerotic lesions.

We report 17 cases of intracranial arterial stenosis treated by percutaneous transluminal angioplasty (PTA), including 9 on the intracranial internal carotid (ICA), 4 on the middle cerebral (MCA), and 4 on vertebrobasilar artery (VBA) system. All patients had ischaemic brain symptoms and stenoses of more than 60% (calculated angiographically). We treated four patients by PTA for residual stenoses after thrombolysis for acute occlusion. We used PTA balloon catheters 2.0-3.5 mm in diameter for all procedures. As a rule, the balloon was inflated for 1 min at 6 atm. All arteries were successfully dilated (stenosis less than 50%) except for one treated by PTA for residual MCA stenosis after thrombolysis. The patient died of a massive infarct due to MCA reocclusion caused by arterial dissection. Stenosis recurred in 4 of 16 patients. Repeat PTA was successfully carried out in these cases. However, stenosis recurred in one of these patients 3 months after PTA, but the patient is being followed because he is asymptomatic. PTA of intracranial arteries is effective, but its indications should be based strictly on potential risks, such as acute occlusion derived from arterial dissection.

Vertebral arteriovenous fistula treated by embolization technique. Report of three cases.

SUMMARY: Three patients with vertebral arteriovenous fistulae are described. Transarterial embolization by microcoils and balloons was used in each case and the fistula was completely occluded in one case immediately after embolization. Another two cases with partial obliteration of the fistula were followed and showed complete occlusion of the fistula after a one year follow-up. After embolization of the fistula, each patient improved in clinical signs and symptoms and showed no complications. Transarterial embolization for vertebral arteriovenous fistula is a safe and effective treatment.

[Combined carotid endarterectomy and coronary artery bypass grafting: a report of two cases].

We reported two cases of successful combined carotid endarterectomy and coronary artery bypass grafting. The first case was a 60-year-old male who had unstable angina pectoris and a history of two times of cerebral infarction. He was revealed to have severe stenosis of left internal carotid artery as well as diffuse stenosis of right and left coronary arteries. The second case, 67-year-old male with a history of cerebral infarction, was admitted because of anterior myocardial infarction. Coronary angiography revealed left main trunk disease and carotid angiography also revealed critical stenosis of bilateral internal carotid arteries. We discussed the management of the patients having coexistent such coronary and carotid artery disease.

[A case of familial insulin resistance due to type A insulin receptor disorder].

We report a case of familial insulin resistance due to Type A insulin receptor disorder. The patient, a product of consanguineous marriage, was a 34-year-old man who had had diabetes mellitus since the age of 14 years. He was treated by insulin therapy but became blind due to diabetic retinopathy at the age of 25 years. He was 154 cm tall and weighed 41kg. He had hirsutism and acanthosis nigricans. Laboratory data revealed hyperinsulinemia (140-350 microU/ml), and glucose clamp study showed insulin resistance, i.e. decreased glucose metabolic clearance rate, 20% of normal. Insulin binding was decreased to 10.7-16.6% of normal in erythrocytes, cultured fibroblasts and transformed lymphocytes. Glucagon stimulated C-peptide levels decreased gradually during a 3 year follow-up period. Homologous missense mutation from Proline193 to Leucine193 was found in this patient. Heterologous mutation was found in his mother who showed mild diabetes but did not show hirsutism or acanthosis nigricans. These findings suggested that the patient's father had this mutation in his insulin receptor gene and that the homologous mutation gene provoked more severe diabetes mellitus than heterologous mutation in this case. The efficacy of sulfonylurea agents was seen in this patient. Furthermore, sulfonyl urea agents may be indicated for treating these patients, probably by increasing insulin sensitivity.

[Malignant transformation of benign mixed tumor of lacrimal gland to squamous cell carcinoma 19 years after initial surgery: report of a case].

A case of malignant transformation of benign mixed tumor (pleomorphic adenoma) arising from the right lacrimal gland is reported. A 63-year-old man was referred to our clinic because of visual disturbance and protrusion of the right eye in January, 1989. His past history revealed that he had had a benign mixed tumor of the right lacrimal gland resected 19 years ago. On CT scan, an iso-density lesion homogeneously enhanced with contrast medium was found in the right orbit. This tumor was partially cystic and invaded the cranial cavity. On T1 and T2 weighted MRI, the tumor appeared as an iso-intensity area. At surgery, the tumor was subtotally resected via the combined fronto-orbital approach on February 3, 1990. Histological diagnosis of the tumor was squamous cell carcinoma, and it was construed to be a malignant transformation of mixed tumor of the lacrimal gland. Postoperatively he was placed on a course of external radiation therapy (63 Gy in total) in combination with intra-carotid Cisplatin injection therapy. The first sign of the recurrence was seen as multiple metastatic lesions in both lungs about 4 months after the surgery. In December, 1990, protrusion of the left eye and disturbance of ocular movement became progressively worse. On CT scan, recurrent metastatic tumor was seen in the left orbit and paranasal sinuses. Although additional chemotherapy and irradiation brought about a short period of symptomatic relief he succumbed to pneumonia in April 18, 1990. Metastatic squamous cell carcinoma was confirmed in the lung at autopsy.(ABSTRACT TRUNCATED AT 250 WORDS)

Autotransplantation of peripheral cholinergic neurons into the brains of Alzheimer model rats.

Current hypotheses regarding Alzheimer's disease implicate cholinergic function. In this study, peripheral cholinergic neurons in the vagal nodosal ganglion were transplanted into the brains of Alzheimer model rats. Eighteen Sprague-Dawley strain rats were divided into three groups: 1) unoperated control rats, 2) rats that had undergone bilateral destruction of the nucleus basalis of Meynert (NBM) (Alzheimer model), and 3) the transplantation group in which the vagal nodosal ganglion was transplanted into the cerebral neocortex one week after the bilateral destruction of the Meynert nucleus. Seven weeks after the transplantation rat behaviour was assessed using psychological tests (spontaneous activity, passive avoidance response and the Hebb-Williams maze test). The Alzheimer model rats had a statistically significant increase in spontaneous activity in comparison with controls (P less than 0.01). The transplant rats showed some amelioration of this abnormal increase in spontaneous activity observed in the Alzheimer model rats. All of the control rats showed conditioned passive avoidance responses, while only one Alzheimer model rat retained is shocked-conditions behaviour before 24 hours (P less than 0.01). Three of the six transplanted rats showed complete improvement in the passive avoidance response test. In the Hebb-Williams maze test, the rats with NMB lesions made more errors than the control rats. The transplanted rats had a lower number of errors than NBM-lesioned rats but still more than the controls. Histological examination revealed many cholinergic cells in the transplanted tissue, especially in the area adjacent to the cerebral cortical surface. The present results indicate that autotransplantation of peripheral cholinergic cells ameliorates abnormal behaviour in Alzheimer model rats.

[Intraarterial injection of low molecular weight dextran and urokinase for acute cerebral infarction].

Strategic recanalization of the occluded cerebral vessels has shown promise as a therapy for embolism and thrombosis in the acute stage. A single-dose of urokinase (UK) administered by intravenous and intraarterial routes was usually designed to restore patency of the infarct-related arteries and reperfuse the area of infarction. However, thrombolytic agents which have been available to date may lack resoluvability, limiting the amount of doses, because overdosage may induce hemorrhagic complication. This newly-designed therapy, intraarterial injection of UK-low molecular dextran (LMWD) complex was introduced in order to overcome the danger shown in the previous study. A high-resolvent allows cut-down of urkinase doses. Patients with acute cerebral infarction were selected for treatment with the resolvent if they satisfied the following conditions: 1) up to 79 years old without serious systemic diseases, 2) less than 12 hours from the onset, 3) better than the score of 8 in GCS, 4) no abnormality in CT scan, 5) apparent neurological deficit and 6) responsible pathology in angiography. LMWD of 15ml, UK of 240000IU and 15ml saline-complex was injected as one course at 2.0-2.5ml/min for 11 cases. Recanalization was observed in seven cases of embolism, and lack of reperfusion in five cases of thrombosis. The minimum effective dose was determined as 480000IU of UK in two courses. In terms of time lag from the onset, six hours may be the inferior limit, within which five of six cases (83%) succeeded in the recanalization.(ABSTRACT TRUNCATED AT 250 WORDS)

Autologous transplantation of the superior cervical ganglion into the brain of parkinsonian monkeys.

The effect of autologous transplantation of the superior cervical ganglion (SCG) into the brain of parkinsonian monkeys was studied through quantitative measurement of animal behavior. The motor activity of the monkey was measured with a telemetry system during the experiment. After experimental parkinsonism was induced by repeated intravenous injection of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP), three monkeys were treated with autologous transplantation of the SCG into both caudate nuclei. One monkey served as a control without SCG transplantation after MPTP treatment. Three SCG-transplanted monkeys showed biphasic (acute and chronic) behavioral amelioration of parkinsonism after transplantation. In the acute stage, the animals showed transient hyperkinesia with aggressive behavior and loss of circadian rhythm. In the chronic stage following acute hyperkinesia, the animals regained normal behavior and circadian rhythm without aggressiveness. In contrast with the transplanted monkeys, the control monkey failed to show recovery of the bradykinesia and muscle rigidity.

[A case of acute myeloblastic leukemia associated with multiple intracerebral hematomas].

A case of acute myeloblastic leukemia associated with multiple intracerebral hematomas is presented. A 19-year-old woman with a two week's history of mild fever suddenly lost consciousness, and was afflicted right severe hemiparesis, left mild hemiparesis and motor aphasia. A CT scan revealed bilateral thalamic hyperdense lesions and paraventricular small hematoma in the right hemisphere. Hematology showed marked leukocytosis (450,000/mm3), mild anemia and no coagulopathy including disseminated intravascular coagulation syndrome. Cytology showed myeloblasts with positive stain in peroxidase and negative in esterase both in cerebrospinal fluid and blood. These findings indicated M 1 type, myeloblastic leukemia without maturation, according to FAB (French-American-British Co-operative group) classification. CT scan on the second day demonstrated expansion of the hematoma in the right thalamus, and nine brand-new small hematomas in different locations. The patient deteriorated into brain death soon after this examination. The pathology of this case was supposed to be "hyperleukocytosis", which is defined as a leukocyte count greater than 100,000/mm3. Severe leukostasis due both to dense leukocytes and lack of mobility of the myeloblast brought about an increase in permeability because of local impairment of nutrition to the walls of the vessels. As a result, the following histological changes occurred: 1) cellular exudation into Virchow-Robin space, 2) the appearance of leukemic nodule, admixtures of leukemic cells and erythrocytes, 3) mechanical compression of the capillaries and venules by the enlarging mass of the leukemic nodules. CT scan showed these characteristics as follows: 1) multiplicity, 2) small-size, 3) cerebral hemisphere, especially in white matter.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of lipolytic and antilipolytic agents on glycerol and free fatty acid release from isolated adipocytes of normal and diabetic rats.

Isolated adipocytes from severely diabetic rats exhibited hypersensitivity to epinephrine at low concentrations (0.05-0.1 microM) on lipolysis, compared with isolated adipocytes from normal and mildly diabetic rats. Hypersensitivity to dibutyryl cyclic AMP and theophylline at concentrations from 0.05 to 0.50 mM was not observed in adipocytes of severely diabetic rats. Insulin could not exert an inhibitory effect on epinephrine-induced lipolysis in adipocytes of severely diabetic rats. In isolated adipocytes from normal rats, hyperosmolarity due to the combination of 50 mM glucose and 100 mM sodium chloride only had an inhibitory effect on 0.25 microM epinephrine-induced lipolysis. Ten mM beta-hydroxybutyrate did not inhibit lipolysis caused by epinephrine although any lipolysis stimulated by epinephrine, dibutyryl cyclic AMP and theophylline was inhibited by insulin. Our present findings may partly explain insulin resistance in the severely diabetic state and the pathogenesis of the absence of ketosis in hyperglycemic hyperosmolar conditions.

Immunohistochemical demonstration of vasopressin nerve fibers in the cerebral artery.

Vasopressin-immunoreactive nerve fibers were demonstrated in the cerebral pial arteries by peroxidase immunohistochemistry. In the large pial artery (proximal part of the middle cerebral artery), they ran longitudinally to the long axis of the vessel. They ran in a spiral pattern in the distal part of the middle cerebral artery. Even in small arteries, vasopressin nerve fibers were found arranged in a longitudinal fashion. The present morphological data suggest that vasopressin nerve fibers in the cerebral artery may play a role in cerebral circulation.

Autotransplantation of the superior cervical ganglion into the brain. A possible therapy for Parkinson's disease.

The superior cervical ganglion (SCG) of rats was transplanted into their own parietal cortex. Four weeks after implantation, catecholamine histofluorescence revealed many transplanted catecholamine cells in the cortex. However, no fibers extended from the transplanted tissue to the cerebral cortex. In a second group of rats which had been pretreated with 6-hydroxydopamine (a specific neurotoxin to the catecholamine neuron), some showed extension of catecholamine fibers to the cerebral cortex. To simulate an animal model of Parkinson's disease, MPTP (1-methyl-4-phenyl-1,2,5,6-tetrahydropyridine) was administered to five monkeys. Two weeks after MPTP administration, dopamine terminals in the caudate nucleus disappeared. After autotransplantation of the SCG into the caudate nucleus of these monkeys, many of the transplanted SCG cells extended axons beyond the graft into the caudate nucleus. These results show that transplanted SCG cells survived well in the brain. Under special circumstances, such as a shortage of catecholamine in the brain, implanted SCG cells extended their axons into the brain. It is suggested that autotransplantation of SCG grafts may be a new therapy for Parkinson's disease.