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For the purpose of continual measurement of the T1 value using the FSE (fast spin-echo) sequence and evaluation of the hemodynamics, we assessed T1 values when the imaging parameters were changed. Moreover, with the imaging parameters derived from this study, dynamic contrast-enhanced MR imaging (MRI) was examined in prostatic disease. First, the T1 value before contrast agent injection was measured with imaging parameters that had different TR and fixed TE. Next, dynamic contrast-enhanced imaging data were acquired for the imaging parameters using TE and TR in the same way as before contrast agent injection, and the T1 value of the tissue at contrast enhancement was measured. In the phantom studies, the TSE imaging parameters with short TE, long TR, and few ETL were connected with the mixed sequence. In dynamic study of the prostate, the difference between normal prostate and prostate cancer became clearer with the time-relaxation rate curve than the time-signal curve. This method using TSE is able to evaluate in greater detail information on hemodynamics and to perform dynamic study with the spin-echo sequence in extensive tissues.

Suginoki Dental Clinic, which is managed by Suginami Dental Association, financially supported by Suginami City, and technically assisted by the University Hospital, Tokyo Medical and Dental University, was established for dental treatment of handicapped persons living in Suginami City, Tokyo who are difficult to be treated by private practitioners. It has one full-time dentist, 12 part-time dentists, two dental hygienists, one nurse, and one clerk; one of the part-time dentists practices twice a week there. Since December 1994, 406 patients visited the clinic and the total cases was 9,273 in December 1999; 99 cases were mentally retarded, 36 autism, and 30 epileptic patients in the younger group; and 65 cases were cerebrovascular disease and 27 cardiac malfunction patients in the older group. Almost all the patients needed special care such as monitoring, intravenous sedation, nitrous oxide sedation, and general anesthesia. Four cases underwent general anesthesia, and no complication was seen among the cases. It was concluded that the clinic has been successful due to a good relationship among the Dental Association, Suginami City, and the dental hospital.

Enhanced US by intraarterial infusion of CO2 microbubbles is useful for segmental to subsegmental TAE of hepatocellular carcinoma for several reasons. First, we can obtain better recognition of the tumor stain of hepatocellular carcinoma which is even faint on DSA. Secondly, we can recognize the co-relation between tumor stain and its related segment or subsegment well. Therefore, subsegmental or segmental TAE can be performed easily and precisely using enhanced US by CO2 microbubbles. We noted the bigger advantage of enhanced US by CO2 microbubbles especially in the repeated treated cases of TAE for hepatocellular carcinoma.

Limb threatening ischemia in patients with atherosclerotic occlusive disease is frequently induced by the association of crural artery occlusion. To improve the patency of distal bypass grafts, we developed a "non-dissection method" for reconstruction of these lesions. This method involves following procedures; an adventitial dissection limited to the frontal surface of the artery at the anastomotic site, complete evacuation of blood from the lower leg using a Esmarch's rubber bandage or a pneumatic tourniquet under systemic heparinization, and distal anastomosis with vein graft in end to side fashion with long arteriotomy (20 mm in length) without use of vascular clamps. This method has several advantages to the conventional method, such as easiness of suturing for accurate anastomosis, preservation of the muscular branches around the anastomosis, avoidance of surgery-induced injury to the artery and prevention of postoperative cicatrization around the anastomosis which may affect natural enlargement of the bypassed native artery. The technical details are described. Since 1982, 76 tibial bypass surgeries were performed using this method. Whenever stenotic lesions were recognized, the grafts were revised and counted as a primary occlusion. The primary patency rates at 1 year, 3 years, 5 years and 10 years are 82.2%. 75.8%, 63.9% and 63.9% respectively. The secondary patency rates are 89.1%, 84.8%, 80.8% and 80.8% respectively at the same term.

The incidence of rerupture during the period of delayed ischemic neurological deficit (DIND) was studied in patients with aneurysmal subarachnoid hemorrhage (SAH) before surgical aneurysmal obliteration, and optimal management of DIND for preventing rerupture is discussed. At Tokai University Hospital, 511 patients with SAH were admitted during the 5-year period from 1988 to 1992. Of these, 247 had not undergone obliteration of the aneurysm neck within 3 days after SAH. In this group, 31% (77 patients) developed DIND. Of these 77 patients, 40 were managed with induced hypertension and/or hypervolemic therapy for DIND (25 with both (group 1), 15 with normotensive hypervolemic therapy (group 2)), and 37 did not receive either kind of therapy (group 3). The incidences of rerupture were as follows: all SAH patients: 11.5%; group 1: 48%; group 2: 7%; group 3: 11%. The incidence of rerupture in group 1 was significantly higher than that in the other groups. On the other hand, the favorable outcome rate (excellent and good) was as follows: group 1: 40%; group 2: 73%; group 3: 22%. This rate was significantly higher in patients who received normotensive hypervolemic therapy, than in other groups. This study suggests that, to avoid rerupture and unfavorable outcome, normotensive hypervolemic therapy is the optimal management approach in patients with DIND after SAH who have not undergone obliteration of the aneurysmal neck.

We previously studied the fatigue and stress of anesthesiologists at work using a flicker photometer, visual reaction time test, questionnaires, and Holter EKG. In the present study, we investigated the fatigue and stress in seven junior anesthesiologists at work using a flicker photometer and a stabilo-meter. The stabilo-meter measures postural stabilization. We performed each test three times on each subject for a total of twenty-one times. The flicker test and the stabilo-test showed the increase in fatigue in 17 (18%) and in 16 tests (76%), respectively, in all seven subjects. Increase of fatigue in both the flicker and stabilo-tests was observed in 13 tests (61%) of 6 subjects. There was a good relationship between the flicker test and the stabilo-test. Therefore, the stabilo-test appears to be a useful method for investigating the fatigue of anesthesiologists.

Clinical trials of TAE using microcoils (Target, USA) coated with n-butyl 2-cyanoacrylate and lipiodol were performed. The procedures were as follows. First, a small amount of lipiodol was injected into a Tracker 18 catheter. Secondly, a microcoil coated with n-butyl 2-cyanoacrylate and lipiodol was inserted into the microcatheter. Thirdly, a small amount of lipiodol was again administered into the catheter just behind the coil. Finally, the coil was pushed safely out from the catheter with a special guidewire. With this method, excellent occlusion of small arteries was obtained. There were no complications.

We analyzed the safety of the segmental-subsegmental TAE for hepatocellular carcinoma in 18 cases of liver hypofunction by checking total bilirubin change after TAE. The TAE was performed safely in all of the cases. The highest value of total bilirubin before TAE was 5.1 mg/dl in the 1-2 subsegment TAE group, 3.8 mg/dl in the 3-4 subsegment TAE group and 2.0 mg/dl in the 6 subsegment TAE group. We conclude that segmental TAE is safe even in the patient of liver hypofunction.

Seventy cases of neonatal hydrocephalus were analyzed regarding the prognosis using the newly developed concept, namely "Perspective Classification of Congenital Hydrocephalus [PCCH]". The results revealed that the prognosis of premature-neonatal hydrocephalus is not necessarily poor even in the early periods of the neuronal maturation (PCCH Stage- II/III). It was suggested that the major underlying pathophysiological difference between the premature-neonatal and fetal hydrocephalus in the same stage of neuronal maturation is the intracranial pressure dynamics. It was concluded that the fetal hydrocephalus should be treated in the early period of neuronal maturation as the form of neonatal hydrocephalus to avoid the insult of such high intracranial pressure dynamics in utero.

We evaluated fatigue, stress and workload of anesthesiologists during anesthetic works using Holter ECG. Recorded heart rates of anesthesiologists enable us to draw the task graph and to calculate the workload scores according to their task behavior. We conclude that the application of Holter ECG is useful in measuring the fatigue, stress, and especially workload of anesthesiologists.

We tried to use nitroglycerin to enhance MR angiography (MRA). Nitroglycerin has an effect to dilate vessels. We made a direct comparison between pre and post enhanced MRA (3 D-TOF technique). MRA after administration of nitroglycerin could depict more details of cortical branches without enhancement of background. So we recommend this method to be used in any examination of MR angiography.

We studied the fatigue and stress of anesthesiologists at work using a flicker photometer, visual reaction time test and questionnaires to them. The two kinds of visual apparatus enabled us to measure two types of fatigue. On the other hand, the questionnaires relating to fatigue and stress indicated the stress tendencies and stressors by age, anesthetic experience, and sex. The results suggest that these methods are useful for measuring the fatigue and stress of anesthesiologists.

Transcatheter embolization therapy using absolute ethanol was accomplished in six patients with renal arteriovenous malformation. The effect of this therapy was considered to be good, because none of the patients has experienced recurrent hematuria. It is necessary to avoid the back flow of absolute ethanol. One patient had the particular complication of hydronephrosis caused by the incidental injection of absolute ethanol into the ureteral artery.

Sixty-three patients (aged from 4 to 75 years) who had suffered severe head injury or cerebrovascular disease were placed on barbiturate regimens in which intravenous administration was given in amounts of 1-4 mg/kg/hr. Dobutamine and dopamine were also administered to prevent cardiac failure and renal failure. Immediate and delayed complications caused by barbiturate therapy were investigated and analyzed. Immediate complications included tachycardia which was seen in 16 cases (25%), and hypotension in 14 cases (22%), respectively. Higher incidence of those complications was noted among the patients who underwent surgery. Delayed complications included hypokalemia (41 cases, 65%), liver dysfunction hypernatremia (24 cases, 38%), infection (21 cases, 33%), cardiac failure (8 cases, 13%) and renal failure (1 case, 2%), respectively. Therefore, in patients treated under barbiturate regimens great care should be taken in order to avoid above mentioned complications.

A thoracoabdominal aortic aneurysm (TAAA) involving major abdominal branches remains still difficult to be managed. From 1983 to 1990, we successfully operated five such cases. Our operative strategy for TAAA which necessitates concomitant reconstruction of four major abdominal branches is i) to utilize temporary bypass to maintain distal perfusion during aortic cross-clamping, ii) to reconstruct bilateral renal arteries prior to aortic clamping in order to shorten renal ischemic time as much as possible, iii) to reconstruct celiac and superior mesenteric arteries by Crawford's method, iv) to reconstruct two pairs of intercostal arteries by using diagonal anastomosis in the proximal site, and v) to divide the left renal vein temporarily for easy manipulation of renal arteries. All five cases were recovered uneventfully. This procedure, in which the renal ischemic time is saved as short as possible, is considered a safe and reasonable one for thoracoabdominal aortic aneurysms.

A simple direct precise localization with a CT scan for convexity lesions is presented. The shape of the normal calvarium was analyzed and a characteristic pattern was obtained, that is, one spherical surface in the frontal area and 6 flat planes in the temporal, parietal and occipital areas. The temporal plane is perpendicular to the orbito-meatal line (OML), while the parietal plane declined 29 degrees in the A-P view, and the occipital plane declined 60 degrees in the lateral view. A summit of these three planes forming the parietal tubercle, and the crest following the tubercle between the parietal and occipital planes were detected either by CT scan, or by palpating the skull. Conventional methods of preoperative localization include measurement and calculation from the base line such as OML, or obtaining a CT scan with a marker on the scalp. The former might have an error that will be amplified in the parietal region that would not be negligible. The latter is a rather troublesome method demanding that the CT scan be taken after shaving the hair. Landmarks utilized for the localization should be identified both on the CT scan and on the scalp or skull. These involved OML, coronal suture, parietal tubercle, inion, pineal body, midline and so on. Of these, the coronal suture runs almost perpendicular to the OML and would be the best landmark for the localization in the parietal area.(ABSTRACT TRUNCATED AT 250 WORDS)

A case of bilateral panophthalmoplegia developed after paranasal malignant lymphoma is described, and previously reported cases are reviewed. A 74-year-old female was hospitalized with the chief complaints of bilateral ptosis and bilateral deep orbital pain that had developed over a 10-day period. Neurological examination revealed bilateral dilated pupils, panophthalmoplegia, and hypalgesia in the area of the ophthalmic nerve on both sides. Laboratory studies and endocrinological examination were free from abnormal findings. Skull X-ray films showed a soft tissue lesion in the sphenoidal and ethmoidal sinus and this was associated with bony structure destruction in the surrounding area. Computed tomography demonstrated a heterogeneously enhanced mass lesion in the paranasal sinus extending into the intrasellar region and bilateral cavernous sinus. Meticulous investigation has so far revealed no distant lesions either in the thoracic or abdominal lesions. Subtotal tumor resection was undergone via the transsphenoidal route at which time tumor extension into the nasal cavity and sellar floor destruction were confirmed. Diffuse and mixed B-cell type malignant lymphoma was the pathological diagnosis. Postoperatively, improvement of abnormalities of pupils, panophthalmoplegia, and ptosis was achieved but this was only transient. Despite focal radiation therapy and repeated chemotherapy, the patient died 14-months after the diagnosis was made. On reviewing the literature, it is shown that the incidence of bilateral panophthalmoplegia among patients who develop disturbance of ocular movement is extremely low (0.4%).(ABSTRACT TRUNCATED AT 250 WORDS)

A clinical trial of whole liver simultaneous dynamic MRI was done. In 23 second whole liver was able to be scanned using parameters of filed echo method as follows: TR = 315 msec, TE = 7 msec, Flip angle = 70 degrees or 90 degrees, MAT = 50%, ECD = 60%, FOV 40 cm and no presaturation. Even 2-3 mm nodules of metastatic tumors and small daughter nodules of hepatocellular carcinoma such as 5 mm were demonstrated in the arterial phase clearly.

A new method was developed to display MR angiographic images. Nine MR angiographic images rotated along the cranio-caudal axis with ten incremental degree were constructed. These images were printed from left-anterior-oblique view to give a stereoscopic effect. With the stereoscopic viewing of these images, multiple stereoscopic images with different viewing directions were observed at once. Anatomical relationships of the vessels were more clearly understood than usual stereoscopic viewing. This multi-directional stereo viewing method is useful to display not only the MR angiographic images but also other multi-viewing techniques.

Magnetic Resonance Angiography using a time-of-flight method was performed on two cases with arterial-portal shunting (A-P shunt). Each case was examined both with and without presaturation applied above the diaphragms. Signal intensity in the portal vein on these cases decreased with presaturation. This presaturation normally eliminates signal from inflowing spins in the artery but never effect on that in portal vein. Therefore the decrease of signal intensity in the portal vein with presaturation indicates the arterial inflow to the portal vein.

A rare case of an abscess in the cavum septi pellucidi (CSP) is described and previously reported cases are reviewed. A 60-year-old male was admitted to the hospital because a diagnosis of cerebellar hemisphere infarction was made on CT scan. Seven years earlier, the patient had undergone a craniotomy for aneurysm clipping, and a ventriculo-peritoneal shunt was installed for normal pressure hydrocephalus 14 days after the aneurysmal rupture. On his second hospitalization CT scan also demonstrated CSP but this was not associated with ventriculomegaly. He was placed on a rehabilitation regimen and his hospital course was uneventful. Two months later, however, he developed hyponatremia due to the syndrome of inappropriate secretion of antidiuretic hormone. After analysis of CSF obtained from the shunting device, a diagnosis of meningitis was made and CSF culture revealed E. coli infection. A part of the peritoneal tubing was torn and missing when the tube was removed from the peritoneal cavity and converted to outer drainage. Being treated with intrathecal and intravenous antibiotics administration, the meningitis subsided. However, CT scan taken twelve days after the onset of the infection showed an abscess in CSP which showed ring enhancement after contrast media. Therefore, the patient continued to receive intravenous antibiotics to counter the mass effect due to the abscess. The abscess had disappeared on follow-up CT scan obtained ten days later. The patient, however, eventually expired after iatrogenic hypernatremia associated with acute renal failure. The patient was submitted to an autopsy. The authors speculate that the abscess developed through a retrograde cisternal route after infection which had originated from bowel perforation by the peritoneal shunt tube.

Thirty-five patients with symptomatic vasospasm (SV) following aneurysmal subarachnoid hemorrhage (SAH) were managed according to a method based on hemodynamic manipulation, monitored by Swan-Ganz catheter. Nine out of these had delayed surgery. For those who developed SV, the pulmonary wedge pressure (Pcwp) and/or central venous pressure (CVP) were immediately increased up to the point at which neurological deficit was reversed by rapid injection of fresh frozen plasma, albuminates, low molecular dextrose, and glycerol. On this regimen, patients were closely observed for any neurological change. Then the hemodynamic parameters were maintained as optimal values until they could be reduced below optimal values without reappearance of neurological deficit. In inoperable patients, special attention was given in making a decision about discontinuing the regimen. The results were compared with thirty-seven patients with SV who were treated with conventional hypervolemic therapy (CHT) by continuous administration of albuminates. In the treatment of CHT, optimal values could hardly be established, so the same hemodynamic parameters were applied in all the cases. From this study, in the majority of the cases optimal values were found as follows: Pcwp up to 10-15 mmHg, and CVP below 11 cmH2O. On the contrary, in 20% of patients, neurological deficit was reversed by increasing CVP to a point not above 7 cmH2O. Correlation between neurological reversal and systemic blood pressure was not statistically significant. After this regimen (OHT), 74% of patients showed immediate improvement after volume expansion, and, in 80%, outcome was good, while 20% died. The motor function at the time of discharge was more than 3 on the manual test in all cases.(ABSTRACT TRUNCATED AT 250 WORDS)

It is well known that orthodontic forces induce pain during tooth movement. However there have been few neurohistological studies on sensational periodontal tissue response to orthodontic tooth movement. So we have many unknown problems about reactions of periodontal nerve fibers during tooth movement. The present study deals with the response of nerve fibers in periodontal ligament of rat molar during experimental tooth movement by means of immunohistochemical method for calcitonin gene-related peptide (CGRP). The results obtained in this study were as follows: 1. In control sections, CGRP-immunopositive nerve fibers were observed both around the root apex and in the intermediate region of the periodontal ligament. Although most of those fibers was distributed around the blood vessels, a few nerves were recognized to terminate in the periodontal fibers. 2. At three days after tooth movement, the CGRP-positive nerves gradually increased in number around the blood vessels. After that, the number of CGRP-positive nerves decreased and no difference of distribution of CGRP-positive nerves was observed between the control sections and the experimental sections at seven days. 3. Especially, at three days when active remodeling of alveolar bone was taking place, a few nerve fibers showing CGRP-immunoreactivity were observed to concentrate around osteoclasts or to migrate Howship's lacunae. These findings showed the dynamic changes of CGRP-immunoreactive nerves in the periodontal ligament during tooth movement, and suggested that this reaction of the periodontal nerves might induce pain in patients. In addition to neurotransmitter function, it was supposed that CGRP directly or indirectly effected the cellular elements and surrounding tissues on peripheral organs such as vascular system and osteoclasts.

A 64-year-old man was hospitalized for massive bleeding from the cutaneous ureterostomy. He had undergone pelvic exenteration with the ureterostomy for rectal cancer invading the bladder five months previously and retrograde ureteric catheters were inserted bilaterally into the ureters. An aortography revealed a pseudoaneurysm of the abdominal aorta in the region transversed by the left ureter. He was successfully treated by en bloc resection of the aortoureteric fistula and the left ureter and repair of the aorta by Dacron patchplasty. Left nephrectomy was also performed because of pyelonephritis. He has had no signs of cancer recurrence or graft infection five years after this operation.

The authors describe a case of persistent primitive hypoglossal artery aneurysm in a 42-year-old woman who had complained of headache, mainly in the occiput, for 5 days prior to admission. Because of a sudden exacerbation of the headache associated with vomiting, she was hospitalized on July 31, 1988. On admission, a cranial computed tomography scan demonstrated a high density lesion in the basal cisterns which suggested subarachnoid hemorrhage (SAH). Right carotid angiography revealed a persistent primitive hypoglossal artery and an aneurysm arising from this artery at the junction of the posterior inferior cerebellar artery. Bilateral vertebral arteries were shown to be hypoplastic. This was followed by a right suboccipital craniectomy on the 6th hospital day at which time a neck clipping was made. Her postoperative course was uneventful. On discharge on August 22, she was ambulatory and had no neurological deficit except for a mild hoarseness which developed after surgery. Well over one hundred cases of persistent primitive hypoglossal artery aneurysm have been reported. However, as far as we could discern, there have been only 9 cases of persistent primitive hypoglossal artery aneurysm including this present case. Most of the cases had SAH due to the rupture of these aneurysms with favorable outcome after the surgery. In addition, some embryological considerations were made.

Carotid angiography was performed on 12 cases of pituitary microadenomas at 2.3 X magnified frontal projection and 3.0 X magnified lateral projection. Magnification carotid angiograms were analyzed to determine the pathologic findings in 12 cases on 23 sides. Carotid angiograms demonstrated compressed posterior pituitary gland in 3 of 12 cases and 4 of 23 sides which resulted from the expansion of pituitary microadenomas. But carotid angiogram failed to demonstrate any evidence of tumor stain, abnormal capsular arteries or hypertrophied inferior hypophyseal arteries. These results suggested that magnification carotid angiography was not a useful diagnostic procedure for the detection of pituitary microadenomas. Intercavernous sinus venography was performed on 12 cases of pituitary microadenomas. The technique consisted in catheterization into the inferior petrosal sinus after puncture of the femoral vein. Injection of 10 ml. of contrast medium into the inferior petrosal sinus at a rate of 5 ml. per second. The base projection is most demonstrable and routinely used. Intercavernous sinus venography identified the presence of microadenoma in 10 of 12 cases and false negative in two cases. Nine of 12 cases demonstrated narrowing, interruption and disappearance of the anterior and inferior intercavernous sinuses. Only 3 of 12 cases demonstrated narrowing of the posterior intercavernous sinus and nine cases demonstrated compression signs of the venous strips of the cavernous sinus.(ABSTRACT TRUNCATED AT 250 WORDS)

A case of central pontine myelinolysis (CPM) following rapid correction of hyponatremia is reported and a review of the literature is made. The patient was a 63-year-old non-alcoholic female who had no liver or kidney diseases in her past history. She was found unconscious after a series of convulsions and was admitted to the hospital. Eighteen months prior to admission, she had a surgery for a ruptured anterior communicating artery aneurysm. Her postoperative course was uneventful except for an urinary incontinence and mild disorientation. She was initially lethargic with conjugate deviation toward right. Nine days after admission, she still remained lethargic, and laboratory studies showed a serum sodium value of 93 mEq/l, serum osmolarity 206 mOsm/l and urine osmolarity 270 mOsm/l when she was clinically diagnosed as having SIADH. She was treated by a strict elimination of water, and administration of sodium, dexamethasone and demeclocycline. In three days, serum sodium was corrected and returned to 137 mEq/l. However, she deteriorated in consciousness and became comatose and developed quadriplegia. CT scans and cerebral angiograms were normal. One month later, another CT scans demonstrated a well-defined hypodensity area in the pons. Brain stem auditory response (BSAR) showed a prolongation of III-V interpeak latency, especially IV-V interval. Her neurological state was essentially unchanged thereafter and she died of septic shock after 12 months' hospitalization. No permission for autopsy was obtained. The clinical course, CT scans and BSAR reported here are indicative of the diagnosis of CPM.

The incidence of a fracture of the sella turcica is reported to be rare and the authors reported a case of a sellar fracture associated with several neurological and endocrinological complications. A 16-year-old boy was struck at the face and the forehead on the road in a motorcycle accident and was hospitalized in a confusional state. Neurological examinations showed dilatation of the both pupils, sluggish light reflex on both sides and bilateral oculomotor palsy but motor weakness or sensory disturbance was not present. On the tenth hospital day, he developed diabetes insipidus and endocrinological examinations disclosed the impairment of GH, LH and FSH reserves, too. Neuroradiological examinations disclosed fractures of bilateral frontal bones and fractures of the left optic canal and ethmoidal roof as well as a fracture of the sella turcica. On the 28th hospital day, he also developed CSF rhinorrhea and pneumocephalus. Surgical repair for the CSF rhinorrhea was performed. Fractures of the sella turcica were reviewed in 23 cases including our personal case and a special consideration regarding the mechanism of sellar fractures and their major complications was made. The authors stressed the early recognition of a fracture of the sella turcica in head injuries, which would suggest a severe hypothalamo-pituitary involvement or other neurological disorders.