The efficacy of MR imaging in subdural empyema.

MRI findings of a 14-year-old boy with subdural empyema (SE) are reported and compared with those of serial CT-scan. He was admitted with fever, headache, right hemiplegia and facial palsy. Initial enhanced CT-scan revealed a slit left lateral ventricle and a shift in the mid-line structures, but failed to detect any SE. MRI at 10 days after admission clearly demonstrated SE as an area of low intensity on T1-weight (T1WI) and very high intensity on T2-weight (T2WI). Post-contrast enhanced MRI (CE-MRI), using Gd-DTPA, showed a contrast enhancement in the wall of SE. However, no definite parenchymal abnormal intensity areas were detected, suggesting that the diagnosis was made sufficiently early for timely treatment and good neurological outcome. CE-MRI proved to be a more powerful and better diagnostic procedure than enhanced CT-scan, and was very useful in determining the state and development of the disease.

[A comparison between stereotaxic operation and conservative therapy for thalamic hemorrhage].

The subjects studied in this report included 17 surgical cases which underwent evacuation of hematoma by means of BRW CT stereotaxic system approximately 14 days after its onset, and 11 non-operated cases. The average age was 65.5 years for the operated and 68.7 years for the non-operated groups. The neurological grades on admission were Grade III or above (slight or mild disturbance of consciousness). The evaluation of the cases was made according to (1) laterality of the hematoma on the left or right, (2) neurological grading, (3) maximum anterio-posterior, lateral diameters, and maximum depth of the hematoma, (4) CT classification (Kanaya, 1981) and ADL (5 grades) at 4.5 months after onset. No correlation was found between ADL and the laterality of the lesion in both groups. As for neurological grading I and ADL on admission, 6/8 cases in the operated and 3/8 in the nonoperated groups recovered to ADL grade 2 or above and 2 bed-ridden cases were included in the latter group. In regard to the extent of the hematoma, the mean ADL was 1.83 in the operated group. While 2.75 in the non-operated group where the hematoma was 25 mm or less in its maximum anterio-posterior diameter. On CT, there existed a significant difference in ADL at IIb and 4/5 of the operated and 1/4 of the non-operated groups appeared to be ADL 2 or above. Assessment of the activities (mental change, willingness) as well as the muscle strength was performed within 3 days after surgery in operated group and 88.2% and 35.3% improvements were observed, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Subarachnoid hemorrhage after preoperative embolization of a cystic meningioma.

We present a case of cystic meningioma accompanied by hemorrhage in the cyst and adjacent subarachnoid space that occurred while preoperative embolization in feeders of the tumor was being applied. The possible reason for the hemorrhage was the sudden dynamic changes in blood flow triggered by the embolization. The changes could have caused multiple ruptures of pathologic small vessels. We recommend that preoperative embolization should be used cautiously in treating cystic meningiomas because of a possible increase in bleeding from pathologic weak vessels.

Neonatal subdural hematoma secondary to birth injury. Clinical analysis of 48 survivors.

In order to evaluate the treatment and prognosis of subdural hematoma in neonates, we analyzed 48 survivors in the 3-year period January 1979 to December 1981. Based on the CT findings, the hematomas were grouped into four types according to location: type I, localized around the posterior interhemispheral fissure (25 cases, 52%); type II, extending from the posterior interhemispheral fissure to the hemispheric convexity (5 cases, 10%); type III, extending from the incisura to the posterior fossa (15 cases, 31%); and type IV, subdural hematoma accompanied by intracerebral hemorrhage (3 cases, 7%). Intracranial pressure was measured via the anterior fontanel in 13 cases. In 10 cases of extensive hemorrhage, the pressure exceeded 200 mm H2O. The age of the patients was from 0 to 7 days. There were 36 mature (75%) and 12 premature (25%) infants. The mothers were primiparous in 27 cases (56%). Fetal presentation was cephalic in 38 cases (79%), in 10 of which (21%) suction delivery was performed, and breech in 11. The fundus oculi was examined in 32 cases. Retinal hemorrhage was noted in 12 cases; it did not correlate with the type of hematoma or the intracranial pressure. Operations were performed in 13 cases; 1 of type I, 4 of type II, 5 of type III, and 3 of type IV. Functional prognoses were found to be as follows: type I, normal 15, abnormal 4, undetermined 6; type II, normal 4, abnormal 1; type III, normal 13, abnormal 1, undetermined 1; type IV, normal 1, abnormal 2 cases.

[The penetration of cefotaxime into the cerebrospinal fluid. Comparison between acute and chronic stages in intracranial diseases].

Two grams of cefotaxime (CTX) were administrated by drip infusion to 10 patients (11 material) with acute or chronic stage of intracranial diseases. Concentrations of CTX in the serum and the cerebrospinal fluid (CSF) were determined at 15, 30, 60, 120, 240 and 300 minutes after injection. The results obtained were summarized as follows: Serum levels: Peak levels of CTX in sera were 66.2 +/- 10.23 (S.E.) micrograms/ml in the acute stage group (ASG), and 75.7 +/- 31.39 (S.E.) micrograms/ml at 15 minutes after injection in the chronic stage group (CSG). There were no significant difference between the 2 groups. CSF levels: Peak levels of the drug in CSF were 1.35-4.32 micrograms/ml in ASG and 0.18-0.7 microgram/ml in CSG. Average concentration at 60 minutes after injection was 1.11 +/- 0.09 (S.E.) micrograms/ml in ASG and 0.30 +/- 0.08 (S.E.) micrograms/ml in CSG. The value in ASG was significantly higher than the value in CSG by t-test. The ratio between CSF and serum levels: The levels increased as time passed in both groups and the values in ASG were higher than those in CSG at all time points. Average ratios at 60 minutes after injection were 3.85 +/- 0.29 (S.E.)% in ASG and 1.12 +/- 0.50 (S.E.)% in CSG. The value in ASG was significantly higher than that in CSG by t-test. From the above results, it is considered that CTX is useful for the prophylaxis of postoperative infections in intracranial diseases.

Non-invasive measurement in intracranial pressure and analysis of the pulse waveform.

Non-invasive measurement of the intracranial pressure (ICP) via the anterior fontanelle by using an applanation transducer has been performed. Recently, a new fontanometer using an applanation transducer has been developed in our department by improving the conventional Statham transducer, P-50 which is currently accepted for its high reliability. In this study, by analysing patterns of the ICP pulse waves obtained from this new fontanometer, its clinical evaluation has been made in 27 neonates and infants in intracranial pathologies. Analysing the ICP waveforms, the first peak (P1) was divided by the following second peak (P2) and the changes in P1/P2 were examined. A differential amplifier, a dP/dt detector, was also used to make it easier to identify the turning point on the pulse waves. The results obtained demonstrated that the waveforms of ICP in neonates as well as infants are influenced by not only the intracranial constituents but compliance of the container such as the scalp, cranium and the meninges.

[Cystic meningioma associated with intratumor and subarachnoid hemorrhage during embolization--a case report].

We present a case of a cystic meningioma accompanied with hemorrhage in a cyst and adjacent subarachnoid space that occurred while preoperative embolization in feeders for the tumor was being applied. A 73-year-old male patient was admitted for a complaint of convulsion. Under CT examination, a tumor was observed at the left frontal convexity and found to be fed by the middle cerebral artery shown in the left cerebral angiograms. The tumor was diagnosed meningioma. After removing the tumor, we conducted histological study. Gross findings of its cross section had an atypical bleeding pattern which was resulted from the ruptures of the criss-crossing internal and external carotid arteries in the tumor. The findings indicated that the tumor was an angiomatous meningioma and contained meningotheliomatous components. The hemorrhage was occurred in the portion of the angiomatous meningioma. The possible reason for the hemorrhage was thought that sudden dynamic changes in blood flow which were triggered by the embolization. The sudden changes could have caused multiple ruptures on pathologic small vessels. Therefore, we strongly recommend that preoperative embolization should be proceeded with caution for exercising a cyst meningioma, since it could increase the possibility of bleeding from pathologic weak vessels.

[Fontanelle pressure in infants (Part II). Discussion on 6 cases of macrocrania].

From the results of ICP determination in 6 cases of macrocrania, it is evident that Lundberg's pressure wave (plateau wave, B wave) can be sufficiently adapted for evaluating abnormality under the semi-closed circumference like infants. ICP determination in the case of macrocrania with mild enlarged ventricles important for knowing pathologic changes. In particular, pressure variation and amplitude changes during REM period seem to be an interesting index for knowing the involvement of venous function. The increased ICP during REM period was also observed in a patient with holoprosencephaly having brain stem formation only, suggesting an important relationship between brain stem and increased ICP during REM period.

[Trial production of non-invasive monitoring system from the anterior fontanelle on intracranial pressure].

The aim of utilizing P-50 Statham transducer as one of the monitoring systems for intracranial pressure consists in the case for its attachment and simplified identification of the zero point and calibration which are of problem for operation as in the cases of electrocardiogram and respiration. The P-50 transducer is a semiconductor strain gage transducer which was developed for the measurement of blood pressure. By attaching the foot plate of it, the applanation principle could be applied and the measurement from the anterior fontanelle could be made feasible. The accuracy of the measurement in this manner could be confirmed by various experiments. Being a semiconductor strain gage, it could be made into an extremely small weight, which made it most adequate for continuous measurement. Although some problems have been left yet to be clarified relative to the method for the fixation, it can be deemed to be fully applicable as one of clinical monitoring systems for intracranial pressure.

Significance of infundibular dilatation in unexplained subarachnoid hemorrhage.

Angiographically equivocal aneurysmal dilatation at the junction of the internal carotid and the posterior communicating arteries was noted in a patient with documented subarachnoid hemorrhage. This was initially thought to be infundibular dilatation. A craniotomy revealed an actual aneurysm, which was obliterated successfully. Whether infundibular dilatation is a preaneurysmal state or a benign dilatation is controversial. The management of angiographically noted infundibular dilatation in cases of "essential" subarachnoid hemorrhage is discussed.