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Granulocyte colony-stimulating factor (G-CSF) inhibits programmed cell death and stimulates neuronal progenitor differentiation. Neuronal stem cells transplanted into injured spinal cord can survive, differentiating into astroglia and oligodendroglia, and supporting axon growth and myelination. Herein, we evaluate the combined effects of G-CSF and neuronal stem cells on spinal cord injury. For 40 Sprague-Dawley rats (n=10 in each group) transverse spinal cord resections at the T8-9 level were carried out, leaving an approximately 2-mm gap between the distal and proximal ends of the cord. Neuronal stem cells embedded in fibrin glue treated with or without G-CSF (50 microg/kg x 5 days) (groups III and IV) or fibrin glue with or without G-CSF (50 microg/kg x 5 days) (groups I and II) were transplanted into the gap in the injured spinal cord. Spinal cord regeneration was assessed using a clinical locomotor rating scale scores and electrophysiological, histological and immunohistochemical analysis 3 months after injury. Regeneration was more advanced in group IV than in groups III or II according to the clinical motor score, motor evoked potential, and conduction latency. Most advanced cord regeneration across the gap was observed in group IV rats. Higher densities of bromodeoxyuridine in the injured area and higher expression levels of Neu-N and MAP-2 over the distal end of the injured spinal cord were observed in group IV compared with groups II or III, but there was no significant difference in expression of glial fibrillary acid protein. This synergy between G-CSF and neuronal stem cells may be due to increased proliferation of progenitor cells in the injured area and increased expression of neuronal stem cell markers extrinsically or intrinsically in the distal end of injured cord.

Autogenous iliac crest bone is the gold standard for graft material in cervical spinal fusion, but a high incidence of donor site morbidity has been reported. Therefore, to achieve a better fusion rate and decrease the rate of donor site morbidity, we used a novel method whereby hollow bone cement filled with impacted cancellous bone is used as a substitute for bone graft in cervical interbody fusion. From 2003 to 2004, 21 patients with cervical spinal disorders who were treated using this method were included in this study. Fourteen patients underwent single-level grafts and seven underwent two-level grafts. Evaluation included a monthly clinical and X-ray examination for the first 3 months, and then follow-up every 3 months thereafter. Multiple-slice computed tomography (CT) scan with reconstruction to evaluate the viability of the bone graft was performed when evidence of bone fusion was found on X-ray. The mean age of the patients was 59 years (range 27-79). The mean follow-up period was 19 months (13-24 months). Evidence of impacted cancellous bone bridging the adjacent vertebral body was observed in all patients at the 6-month follow-up based on X-rays and reconstructive CT scans. No severe donor site morbidity occurred. One patient experienced hardware failure due to screw fracture, but a reconstructive CT scan revealed well-bridged cancellous bone between the vertebral bodies. Hollow bone cement filled with impacted cancellous bone could be an alternative material for cervical spine interbody fusion. Using this method, we found not only satisfactory growth of cancellous bone in the holes of the bone cement, but also low morbidity in the donor site. However, for this method, the long-term stability, potential complications, and the necessity of instrumentation all require further investigation.

Introduction: Problem-based learning (PBL) embraces principles of good learning and teaching. It is student-directed, fosters intrinsic motivation, promotes active learning, encourages peer teaching, involves timely feedback, and can support student self and peer assessment. The most important function of the assessment process is to enhance student learning, to improve the curriculum and to improve teaching. Materials and Methods: To improve the PBL tutorial in Chung Shan Medical University, we developed an online evaluation system containing the evaluation forms for students, tutor, self and peer. The Cronbach α reliability coefficients were 0.9480, 0.9103, and 0.9198 for the Student, Tutor and Self and Peer Evaluation Form, respectively. The online evaluations were mandatory to both students and tutors, and the information was completely anonymous. Results and Conclusions: The survey response rates of the online evaluations ranged from 95.6% to 100%. The online evaluations provided a documented feedback to the students on their knowledge, skills and attitudes. Correspondingly, tutors too received feedback from students in evaluating their performance on the appropriateness and effectiveness of tutoring the group. Although there was an initial lack of coordination regarding responsibilities and how to use the online system for both students and the Faculty, the system enabled us to look into how effective our PBL course had been, and it provided both process and outcome evaluations. Our strategy for evaluating the success of PBL is only at its initial stage; we are in an ongoing process of collecting outcome data for further analysis which will hopefully provide more constructive information to the PBL curricula. Key words: Facilitator, Formative evaluation, PBL tutors, Small group

Summary Objective . With the advent of interventional neuroradiology and stereotactic radiosurgery, dural arteriovenous fistulae are less often managed with open surgery. We evaluated the outcome of dural arteriovenous fistulae of the cavernous sinus treated with a combination of radiosurgery and embolization. Material and methods . Twenty dural arteriovenous fistulae located in the cavernous sinus were enrolled in our study. Fifteen patients received X-knife radiosurgery alone and 5 also required embolization, one before radiosurgery and 4 after radiosurgery. The mean volume of the lesions was 2.8 ml (range 0.2–12.6), the corresponding radiation volume was 6.5 ml (range 0.6–24.6), and the conformity index was 2.9 (range 1.8–5.3). The mean peripheral and maximum radiation dose was 17.8 Gy (range 17–20) and 28.3 Gy (range 19–37) Gy, respectively. The clinical and imaging data were analyzed. Results . The mean follow up period was 29 months (23–39). Seventy-five percent (15/20) of patients receiving radiosurgery alone achieved a symptomatic cure and with additional embolization 90% (18/20) were cured. All patients achieved cure on imaging after radiosurgery alone or in combination with embolization. Abnormal imaging findings were observed in two patients after treatment, one had an intracerebral hemorrhage and the other radiation edema, but both were asymptomatic. Conclusion . With multidisciplinary treatment with combined radiosurgery and embolization, satisfactory results can be achieved for dural arteriovenous fistulae with a low complication rate. In patients with mild symptoms, radiosurgery is the initial treatment option. Embolization should be performed in patients with severe symptoms or who have failed radiosurgery.

We report a case of calcified chronic encapsulated intracerebral haematoma (ICH) in a 29-year-old female who presented with progressive left sided weakness and intermittent seizures since childhood. The preoperative magnetic resonance (MR) imaging of the head initially suggested that a partially thrombosed aneurysm or vascular malformation was present. However, no vascular stain was found on the digital subtraction angiography (DSA) of both the carotid and vertebral arteries. The excised mass was histologically diagnosed as a chronic ICH. We traced the patient's medical history and found that at the age of one she sustained a head injury after a fall. So far, to our knowledge, no case of epilepsy secondary to a calcified chronic encapsulated ICH occurring 28 years after head injury has been reported. Calcified chronic encapsulated ICH concomitant with new bone formation within is even rarer. The possible pathogenesis of this case is discussed.

Neuronavigation is increasingly being used to assist in stereotactic neurosurgery due to its frameless property. In this study, we developed and assessed a modified method of performing stereotactic brain biopsies by combining the use of the Fisher stereotactic biopsy instrument, that was fixed on universal quick-lock holder, under infrared guidance of the BrainLab VectorVision Neuronavigation system. Eighteen patients received a frameless stereotactic procedure in this study, including 5 cases of brain biopsy, 2 cases of abscess aspiration, 10 cases of hematoma aspiration and one case of Ommaya reservoir implantation. All cases were on target and successful. In this paper, we present our technique, discuss the advantage and disadvantages of the method and review the literature.

In this study, we investigated the dose-effect relationship and safety of tissue plasminogen activator (tPA) for the treatment of intraventricular hemorrhage/hematoma (IVH) in rats. Adult male Sprague-Dawley rats were injected with autologous blood into the left lateral ventricle to establish IVH. Two hours later, Ringer's saline or 0.25-2 microg of tPA were administered directly to the IVH over 3 h. The regional cerebral blood flow (rCBF) on the surface of the left parietal cortex was measured with laser Doppler flowmetry. Twenty-four hours after the build-up of IVH, the brains were removed for morphometrical and histological studies. A dose of 0.5-2 microg tPA significantly diminished the IVH in a dose-dependent manner (p0.001). However, only the dose of 0.5 microg tPA significantly ameliorated the reduction of rCBF 24 h after IVH (p0.01). TPA did not improve the ventricular dilatation on the side with IVH. Instead, 1-2 microg of tPA caused additional injuries, including intraventricular leukocytosis and edema of periventricular tissues and choroid plexus on both hemispheres. These results indicate that higher doses of tPA may have detrimental effects on the brain. The dosage rate of 0.5 microg seems beneficial to treat 5 microl of IVH (equals to a dose of 0.1 mg/ml blood) in our model in terms of the satisfactory fibrinolysis and less damage to the brain.

Object. Bilateral subaxillary transthoracic endoscopic sympathectomy (TES) is a popular procedure of upper thoracic sympathectomy. The anatomical locations of the T-2 and T-3 sympathetic trunks, as viewed under the endoscope, are varied in the rib head areas. In this study, the authors investigated the more visible anatomical locations of the T-2 and T-3 sympathetic trunks, the so-called nerves of Kuntz, and intercostal rami by performing transthoracic endoscopy. Methods. Seventy patients with palmar hyperhidrosis undergoing bilateral TES (140 sides) via the anterior subaxillary approach were included in this study. The operative findings and video images of the T-2 and T-3 sympathetic trunks and ganglia were recorded and analyzed. The anatomical locations of the T-2 and T-3 sympathetic trunks along the horizontal axes of the rib heads were determined using a three-region system constructed by the authors. The area between the rib neck and the medial border of the rib head was equally divided into Region E (external half) and Region M (medial half). The area between the medial border of the rib head and the paravertebral ligament was defined as Region I. The incidence of the T-2 and T-3 sympathetic trunks found in Regions E, M, and I were 31.4 to 42.9%, 50 to 57.1%, and 7.1 to 11.4%, respectively, on the left side, and 24.3 to 34.3%, 57.1 to 65.7%, and 8.6 to 10%, respectively, on the right side. One right (1.4%) and six left (8.6%) Kuntz nerves originating from the T-3 sympathetic trunk were found in seven patients (10%). The intercostal ramus was found around the T-2 rib neck in 24 patients (34.3%), with 18 cases (25.7%) for each side. The intercostal ramus around the T-3 rib neck was found in 17 patients (24.3%): 12 (17.1%) on the right and nine (12.9%) on the left. Conclusions. These results indicate that approximately 90% of the T-2 or T-3 sympathetic trunks are located on the rib head. These findings may also be used to assist the surgeon in fluoroscopic guidance for locating the T-2 and T-3 sympathetic trunks during posterior percutaneous sympathectomy.

OBJECTIVE Our previous study demonstrated that a high concentration of phenol (75–90%) with minimal volume (0.02 ml) can elicit serious degeneration of ganglion cells of the stellate ganglia in cats. Another previous study in our clinical patients demonstrated that approximately 84 to 90% of the upper thoracic (T2–T3) sympathetic trunks can be found under an endoscope on the ventral side of the T2–T3 rib heads. In this report, we present a new mode of dorsal percutaneous thoracic phenol sympathicolysis (PTPS) for the treatment of palmar hyperhidrosis or axillary bromidrosis. METHODS Fifty patients with palmar hyperhidrosis or axillary bromidrosis were injected with 75% phenol into a total of 98 sides of the T2–T3 or T3–T4 sympathetic trunks and ganglia. The injected volume was 0.6 to 1.2 ml (average, 0.8 ml) for each side. The technique of dorsal percutaneous injection was performed under local anesthesia or local with intravenous general anesthesia and under the guidance of a C-arm fluoroscope. RESULTS Forty patients (80%) showed satisfactory results, including cessation of sweating. The success rates of PTPS were 83.7% (41 of 49 patients) on the left side and 91.8% (45 of 49 patients) on the right side. The skin temperature of the thumb increased by 5.3 to 5.4°C approximately 1 hour after the phenol injection in patients with satisfactory results, whereas it increased by only 1.3 to 2.7°C in patients who had unsatisfactory results. CONCLUSION PTPS may be a good alternative to endoscopic sympathectomy to treat palmar hyperhidrosis and axillary bromidrosis. The skin temperature of the thumb is still a useful index to evaluate preliminarily whether PTPS has been successful.

This prospective epidemiological survey of spinal cord injury (SCI) in Taiwan was carried out by recruiting patients attended by physicians from various medical centers and general hospitals all over Taiwan from July 1992 to June 1996. A total of 6,410 cases of traumatic spinal fracture were registered among which were 1,586 new cases of SCI. The results represented 70% of the scope of SCI in Taiwan. The observed average annual incidence of SCI in Taiwan was 18.8 per million population. The mean age was 46.1 years-old with a plateau distribution for over 20 years and older. Geriatric victims are a major group of SCI in Taiwan. The male to female ratio was 3 to 1. The leading causes of SCI were traffic accidents and accidental falls. Motorcycle collisions accounted for 62% of the traffic accidents, and as most of the motorcycle riders were not helmet users, head injury became the major associated injury of SCI in Taiwan. The effectiveness of the comprehensive care system for SCI patients in Taiwan is relatively good, as reflected by the low rates of complications of SCI, the low mortality rate (6.6%) and the high percentage (67.4%) of SCI patients achieving self-care ultimately at home after rehabilitation. The analysis of person days healthy life loss and quality adjusted survival time revealed that SCI patients in Taiwan required 4 years to cope with the morbidity, and on average, could return to the main stream of life for another 30 years.

We report an 8-year-old boy with a primary intrasellar mixed germ-cell tumor who underwent the trans-sphenoidal approach for tumor removal. Initially he suffered from diabetes insipidus. Precocious puberty and left abducens nerve palsy were also observed. Elevation of serum testosterone, beta-human chorionic gonadotropin (HCG), and alpha-fetoprotein (AFP) were found on admission. The histological study revealed mixed cellular types of tumor including germinoma, choriocarcinoma, embryonic cell carcinoma, and teratoma. Postoperative radiation to a total of 5000 cGy was performed. Adjuvant chemotherapy was administered before and after radiation. The boy was disease-free during a 6-month follow-up period. Follow-up magnetic resonance imaging showed no presence of tumor. The signs of precocious puberty disappeared, and the diabetes insipidus was easily controlled. The abducens nerve regained normal function. Serum HCG, AFP, and testosterone levels all returned to normal. Serum antidiuretic hormone increased to reach the lower limit of the normal range.

This prospective epidemiological survey of spinal cord injury (SCI) in Taiwan was carried out among patients attended by physicians from various medical centers and general hospitals all over Taiwan from July 1992 to June 1996. In all, 1,586 new cases of SCI were registered, representing about 70% of all possible SCI cases in Taiwan. The observed average annual incidence of SCI in Taiwan was 18.8 per million people, whereas it was 47.5 for the geriatric section. The mean age was 46.1 years with a plateau distribution after 20 years and older. Geriatric victims (297 cases, 18.7%, group II) formed a major section of SCI cases in Taiwan. Another group of younger SCI patients (15-64 years old, 1,232 cases, group I) was selected for comparison. The results showed that the male-to-female ratio, pattern of neurological deficits, and causes of injury and death of geriatric SCI patients differed significantly from those of the younger SCI group. Elderly women were exposed to a higher risk of SCI than younger women (M/F ratio 1.7:1). Falls were the leading cause of geriatric SCI, and two thirds of them occurred on level ground. Traffic accidents accounted for a third of SCI cases, half of which involved motorcycle accidents, a fifth of them pedestrians. Quadriplegia and quadriparesis occurred more frequently among elderly cases of SCI than in the younger group and a higher proportion of them died of SCI complications. Two thirds of elderly SCI patients recovered well enough after comprehensive treatment to be able to take care of themselves at home. The government should initiate programs of prevention to reduce the prevalence of geriatric SCI in Taiwan.

Study Design. This is a report of a man with carcinoma of the anus and intradural metastasis to the cauda equina. Objective. To perform a laminectomy with tumor removal for relief of pain. Summary of Background Data. Only 25 cases of intradural spinal metastasis have been reported in the English literature. This is the first report of a metastatic case, moving from the carcinoma of the anus to the cauda equina. Methods. Magnetic resonance imaging showed an ill-defined mass, with central necrosis, to the cauda equina. The possibility of intradural metastasis to the cauda equina was indicated by unique pain symptoms. Results. The patient's back pain subsided after total laminectomy of L3-L5 with subtotal removal of the tumor. The residual tumor became smaller with postoperative radiation. Conclusion. Magnetic resonance imaging is a good diagnostic choice in this situation. The cause of the metastasis was unclear, but is was presumed to have occurred through the perineural lymphatic ducts. Laminectomy with tumor removal is feasible for relieving pain and demonstrating pathology.

Clearance of fibrin and associated inflammatory cytokines by tissue-type plasminogen activator (t-PA) is related to improved regeneration in neurological disorder. The biological activity of fermented soybean (natto) is very similar to that of t-PA. We investigated the effect of the dietary supplement of natto on peripheral nerve regeneration. The peripheral nerve injury was produced by crushing the left sciatic nerve with a vessel clamp in Sprague-Dawley rats. The injured animals were fed orally either with saline or natto (16 mg/day) for seven consecutive days after injury. Increased functional outcome such as sciatic nerve functional index, angle of ankle, compound muscle action potential and conduction latency were observed in natto-treated group. Histological examination demonstrated that natto treatment improved injury-induced vacuole formation, S-100 and vessel immunoreactivities and axon loss. Oral intake of natto prolonged prothrombin time and reduced fibrinogen but did not change activated partial thromboplastin time and bleeding time. Furthermore, natto decreased injury-induced fibrin deposition, indicating a tolerant fibrinolytic activity. The treatment of natto significantly improved injury-induced disruption of blood-nerve barrier and loss of matrix component such as laminin and fibronectin. Sciatic nerve crush injury induced elevation of tumor necrosis factor alpha (TNF-alpha) production and caused apoptosis. The increased production of TNF-alpha and apoptosis were attenuated by natto treatment. These findings indicate that oral intake of natto has the potential to augment regeneration in peripheral nerve injury, possibly mediated by the clearance of fibrin and decreased production of TNF-alpha.

Amniotic fluid mesenchymal stem cells (AFS) harbor the potential to improve peripheral nerve injury by inherited neurotrophic factor secretion, but present the drawback of the short-term survival after transplantation. Granulocyte-colony stimulating factor (G-CSF) has a diversity of functions, including anti-inflammatory and anti-apoptotic effects. This study was conducted to evaluate whether G-CSF could augment the neuroprotective effect of transplanted AFS against peripheral nerve injury. The potential involvement of anti-inflammation/anti-apoptosis effect was also investigated. Peripheral nerve injury was produced in Sprauge-Dawley rats by crushing left sciatic nerve using a vessel clamp. The AFS were embedded in fibrin glue and delivered to the injured site. G-CSF (50 microg/kg) was administrated by intra-peritoneal injection for 7 consecutive days. Cell apoptosis, inflammatory cytokines, motor function, and nerve regeneration were evaluated 7 or 28 days after injury. Crush injury induced inflammatory response, disrupted nerve integrity, and impaired nerve function in sciatic nerve. Crush injury-provoked inflammation was attenuated in groups receiving G-CSF but not in AFS only group. In transplanted AFS, marked apoptosis was detected and this event was reduced by G-CSF treatment. Increased nerve myelination and improved motor function were observed in AFS transplanted, G-CSF administrated, and AFS/G-CSF combined treatment groups. Significantly, the combined treatment showed the most beneficial effect. In conclusion, the concomitant treatment of AFS with G-CSF augments peripheral nerve regeneration which may involve the suppression of apoptotic death in implanted AFS and the attenuation of inflammatory response.

The time window in the treatment of ischemic stroke with tissue plasminogen activator (tPA) is narrow, arbitrarily within 3 hours after the onset of symptom. Hemorrhagic transformation resulting from cerebral ischemia may be related to damage of the microvascular basal lamina of the brain, which may in turn cause microvascular fibrin deposition and aggravate cerebral ischemia. Here, we investigated the effect of tPA on the microvascular tissue changes during cerebral ischemia/reperfusion. Sprague-Dawley rats were subjected to focal cerebral ischemia by ligation of the right middle cerebral artery and bilateral common carotid arteries for 90 minutes. Sixty minutes after the onset of ischemia, escalated dosages of tPA from 2.5 to 10 mg/kg or saline were intravenously infused for 60 minutes. Twenty-four hours after reperfusion, the animals were allowed to be killed for examination. Low dosage of tPA (2.5-7.5 mg/kg) reduced post-ischemic brain infarction, suppressed metalloproteinase 2 (MMP-2) activity and restored blood-brain barrier (BBB) integrity. In contrast, high dose of tPA (10 mg/kg) aggravated brain infarction, increased MMP-2 activity and exacerbated BBB disruption. Cerebral ischemia/reperfusion decreased the immunoreactivity of both collagen type IV- and laminin-positive microvessels, whereas the low dosage of tPA (2.5-7.5 mg/kg) attenuated the reduction. When these molecules in whole cortical tissues were analysed, tPA dosage-dependently decreased the total content of collagen type IV, laminin and fibronectin. Although the detailed mechanisms regarding the action of tPA are yet to be investigated, our findings demonstrate that the detrimental effect of tPA was mediated, at least in part, through the destruction of the basal lamina in the cerebral microvessels by activating MMP-2.

Objective Amniotic fluid mesenchymal stem cells (MSCs) have the potential to differentiate into neuronal stem cells in vitro. We evaluated using amniotic fluid MSCs to support or enhance the ability of the injured sciatic nerve to cross a nerve gap. Materials and methods We created a 5 mm nerve defect in Sprague Dawley rats. One group received therapy with MSCs embedded into woven oxidised regenerated cellulose gauze (Surgical; Ethicon, Somerville, NJ) and fibrin glue, while a control group received woven Surgicel and fibrin glue only. Evaluation methods included behavioural, electrophysiological and immunohistochemical studies. Results In gait analysis, the angle of the ankles in the treatment and control group were 46.4° (standard deviation [SD] = 15°) and 36° (SD = 8.2°), respectively, which was statistically significant ( p = 0.045). Five of 10 treated rats (50%) demonstrated partial foot movement, while none of the control group had any movement. The percentage amplitude of muscle compound action potential in the experimental group was 43% (SD = 12.5%) compared to 29% (SD = 8.8%) in the control group ( p = 0.038). The conduction latencies in the control and experimental groups was 2.5 ms (SD = 0.45) and 1.7 ms (SD = 0.47), respectively ( p = 0.005). Histological examination demonstrated that 70% of the treatment group achieved a maximum axon diameter percentage across the nerve gap of greater than 50%, compared with 0% in the control group. There were no differences in direction of fibre growth and fibrotic reaction between the two groups. Conclusion Amniotic fluid MSC can augment growth of injured nerve across a nerve gap. This effect may be due to neurotrophic or induction effects of the MSC interacting with Schwann cells. Further study is required to determine the underlying mechanism of this effect.

We report a case of primary intraventricular malignant meningioma in a 74-year-old man who presented with progressive weakness of the left limbs and dizziness, The preoperative magnetic resonance (MR) imaging of the head initially suggested that a glioblastoma multiforme or a metastatic lesion might be present. But later, the excised tumor was histologically diagnosed as a primary malignant meningioma. So far, only a few cases of intraventricular malignant meningioma have been reported. The MR imaging of this tumor has rarely been described in the literature. In the present case, the mass lesion showed hyperintensity on the T1-weighted image (T1WI) and hypointensity on the T2-weighted image (T2WI) which was not commonly seen in meningioma. The unusual MR imaging of this case may be attributed to the intratumoral hemorrhage. Although intraventricular malignant meningioma is difficult to diagnose based on MR or computed tomographic images alone, the characteristics of the MR images in the present case may offer an option for preoperative differential diagnosis of intraventricular tumors.

Intra-extracranial hemangiopericytomas (HPCs) are rare vascular neoplasms. This paper reports the clinical manifestations, histopathological features, diagnosis, treatment, and outcomes of HPCs.We reviewed three patients with intracranial HPC and one patient with HPC of the scalp who were surgically treated at Taichung Veterans General Hospital between 1989 and 1999.All four patients underwent surgery and postoperative radiotherapy. After surgery, three patients showed improvement compared with their preoperative neurological function. Two patients had recurrent tumors, one patient was well and free from tumor recurrence, and one patient was lost during follow-up.Clinical presentation and radiographic appearance of intracranial HPC can be indistinguishable from meningioma. Intracranial HPC is an aggressive neoplasm with malignant potential. Both benign and malignant variations of HPC of the scalp exist. The principal treatment is surgical excision. Survival is influenced by more aggressive primary resection and by postoperative radiotherapy. Recurrences are common. Metastases may be multiple and can develop in many organs and systems.

Patients with hypertensive intracerebral hemorrhage (ICH) are at risk for delayed neurological deterioration, especially during the second week after onset. Mass effect due to vasogenic edema caused by ICH has been shown to cause later deterioration. Control of brain edema and increased intracranial pressure (ICP) are related events that determine outcome. In this study, we compared the effects of three different treatments on brain edema caused by ICH.Thirty-nine patients with ICH were involved in this study. Of these patients, 11 had medical therapy (group A), 15 were treated with stereotactic aspiration plus local administration of urokinase (group B), and 13 underwent conventional craniotomy and hematoma removal (group C). The intracerebral hematoma volume on admission was measured on the the brain computed tomographs (CTs), and the cerebral edema volumes surrounding the hematoma were assessed with CT scans every 5 to 7 days after symptom onset.The median intracerebral hematoma volumes were 23, 50 and 51 ml in groups A, B and C, respectively. Peak edema volume surrounding the hematoma was observed 5 to 15 days after symptom onset. A significant correlation (p0.05) was noted between peak edema and hematoma volumes in all groups. The ratio of median peak edema volume to median hematoma volume was 3.280 in group A, which was significantly higher than those in group B (0.745) and group C (0.863) (p0.05).The study revealed that brain edema induced by hypertensive ICH could be significantly ameliorated by surgical management. Stereotactic aspiration with local administration of urokinase was as effective as conventional craniotomy in reduction of brain edema volume caused by ICH and was characterized by its minimal invasiveness, easy performance, and safety.

Being the most common childhood tumor to involve the hypothalamus and pituitary gland, craniopharyngioma, a histologically benign tumor, is usually related to growth retardation and hypogonadism. The presentation of precocious puberty is very rare for a hypothalamic craniopharyngioma. Here, we report such a case. The female patient had presented with symptoms of menarche and breast development since she was 6 years old. Hormonal therapy with a gonadotropin-releasing hormone analogue was instituted to cease precocious puberty but was unsuccessful. Magnetic resonance imaging of the sella showed a 1-cm tumor in the hypothalamic area. Through a pterional approach, the tumor was removed en bloc with endoscope-assisted microsurgery. After the operation, our patient’s symptoms improved, so the hormone therapy was discontinued. This extremely unique association of craniopharyngioma and precocious puberty, the causes and mechanisms involved along with the advantages of endoscope-assisted microsurgery are discussed.

In recent decades, there has been an increase in both the number of sympathectomy techniques, as well as the surgical findings of sympathetic anatomy. Currently the advanced technique of C-arm guided percutaneous thoracic chemo-sympathectomy is widely used for the treatment of palmar hyperhidrosis. However, a better understanding of chemical agents in sympathectomy is required. In this study, chemo-sympathectomy was performed in cats, using alcohol, glycerol and various concentrations of phenol, to determine the chronic neurotoxic effects of these chemical agents on the stellate ganglia. The stellate ganglia of 24 cats were exposed under endotracheal general anesthesia, then injected with about 0.02 ml of absolute alcohol, glycerol and phenol (10%, 25%, 50%, and 75% concentration) solutions, respectively. The stellate ganglia were taken for histological examination three weeks after the chemical injection. The results showed that the degenerative changes in the cytoplasm and nucleus of ganglionic cells and intercellular tissue were moderate and relatively moderate after the injection of alcohol and glycerol, respectively. Meanwhile, the stellate ganglia revealed mild, relatively moderate, serious and extremely serious degeneration after injection of 10%, 25%, 50%, and 75% phenol, respectively. In conclusion, we recommend a high concentration of phenol, in the least volume, as a chemical agent for clinical injection in the upper thoracic sympathetic ganglion.

Study design This report analyzed the likely locations of lesions that cause a combination of Horner's and Brown-Sequard syndromes. One must know the anatomic structure of spinal cord and the sympathetic nerve chain. Objectives A hypertensive patient had Brown-Sequard and Horner's syndromes after neck trauma. The magnetic resonance imaging and surgical findings showed the correlation between the clinical symptoms and the likely lesion. Methods The patient underwent right hemilaminectomy from C2 to C6 with total removal of hematoma. Conclusion The spinal epidural hematoma rarely is a surgical emergency. The patient presented with Brown-Sequard and Horner's syndromes. Magnetic resonance imaging made a rapid and correct diagnosis. The patient received an emergent right hemilaminectomy from C2 to C6 with removal of hematoma and subsequently made a complete recovery.

For the study of pathogenesis and treatment of recurrent trigeminal neuralgia, we performed 31 repeat operations from among 400 patients with trigeminal neuralgia in the past 10 years. Initially, of these 400 patients, 376 underwent microvascular decompression only, and 24 underwent partial sensory rhizotomy with or without microvascular decompression. Fifty-three patients (14%) had recurrences after microvascular decompression, of which 31 patients underwent repeat operations. Among the repeat operations, there was negative exploration in 16 patients (52%), arterial loop compression in 7 (22%), venous compression in 4 (13%), and Teflon compression or adhesion in 4 (13%). Twenty-one patients had early recurrences within 1 year, and 10 patients had late recurrences. Negative exploration and arterial compression were more likely in early recurrence (P = 0.01). Continuing demyelination might occur in patients with negative exploration, even when adequate decompression had been initially performed. Seventy percent of the patients had no recurring pain by way of partial sensory rhizotomy for negative explorations, redecompression of arterial loops, division of offending veins, or lysis and reposition of Teflon. About half of the patients had positive findings that were amenable without rhizotomy in the repeat operations. A repeat operation for failed microvascular decompression is a good choice if the condition of the patient is tolerant.

A permanent human brain malignant glioma cell line, GBM8401/TSGH,NDMC, has been successfully established from a 31-year-old Chinese female with brain glioblastoma multiforme (GBM) in monolayer culture and has been subcultured for more than 100 passages during 24 months in vitro. The tumor cell doubling time in vitro was approximately 38 hr. The tumorigenicity in athymic nude mice was observed; the tumor volume doubling time was approximately 4 days. Glial fibrillary acidic protein (GFAP) and 10-nm-diameter intermediate filaments were identified by immunohistochemical peroxidase-antiperoxidase (PAP), immunofluorescence assay, and transmission electron microscopic methods. The scanning electron microscope revealed numerous surface microvilli and various-sized blebs. Karyotypic analysis showed this malignant glioma cell line to be of human origin, near-diploid with a modal chromosome number of 48,XX.

We used intracerebral administration of clonidine in monkeys to map effective sites for analgesia. The jaw opening reflex elicited by tooth pulp stimulation was used for analgesia testing. We found that the most consistently effective sites for analgesia in monkeys are in at least three brain regions: the diencephalic periventricular gray, the dorsal raphe nuclei, and the periaqueductal gray. In addition, the analgesia induced by intracerebral administration of clonidine was effectively antagonized by pretreatment of animals with either naloxone (a narcotic antagonist) or yohimbine (an alpha-adrenergic antagonist). These results suggest the existence of an opiate and an adrenergic antinociceptive mechanism in the diencephalic periventricular gray, the dorsal raphe nuclei, and the periaqueductal gray activated by clonidine in primates.

Three cases of organized intracerebral hematomas presented slowly progressive neurological deficits and hence mimicked brain tumors. Computed tomography scanning revealed ring enhancement of intracerebral mass lesions with midline shift. Angiographic studies showed avascular mass lesions. Soft, well-encapsulated, organized, large intracerebral hematomas with feeding arteries on their capsules were removed surgically. The lesions contained fresh and old hemorrhages. It is presumed that the feeding artery caused slowly continuous bleeding, thus causing these intracerebral hematomas to grow in a manner that made their clinical picture simulate that of intracerebral neoplasms. Their pathogenesis is discussed.

✓ The authors describe a case of a spinal intramedullary pseudocyst at T-1 that did not communicate with the surrounding spaces. The cystic wall was composed of dense connective tissue without epithelial or neoplastic cells. The patient's condition improved dramatically after surgical removal of the cyst. The literature on spinal intramedullary cystic lesions is reviewed and the etiology of pseudocysts is discussed. This case is believed to be the first in which a pseudocyst has been demonstrated within the spinal cord.

1. The response of cerebral blood vessels to hyperosmolar agents in vivo remains controversial, and little is known about the effect of glycerol on cerebral vessels. In this study we investigated the cerebrovascular response to intravenous administration of glycerol (1 g/kg, infused over 25 min) in dogs under pentobarbital anaesthesia. 2. Intracranial pressure, systemic arterial pressure, mean arterial blood pressure, serum osmolarity and packed cell volume were continuously monitored, and blood gases were checked frequently. Through a parietal cranial window, pial vessel diameter was measured by means of a surgical microscope and a video image-analyser. 3. Pial vessel diameter increased gradually with a maximum at 30 min after the beginning of glycerol infusion. The maximum increase in diameter in small (< 100 μm) vessels was 14.3%, whereas that in large (> 100 μm) vessels was 10.3%. There was only a slight increase (< 4%) in pial vessel diameter in vehicle-infused animals. The intracranial pressure decreased drastically after glycerol infusion, whereas the mean arterial blood pressure remained constant. There were correlations between the rise in serum osmolarity, fall in packed cell volume and vasodilatation, indicating that glycerol caused vasodilatation accompanied by plasma volume expansion. 4. Our data suggest that glycerol produces cerebral vasodilatation, which might be beneficial in cerebral ischaemia and vasospasm, in addition to its intracranial pressure-reducing effect on normal or oedematous brain. The degree of vasodilatation was not sufficient to affect the predominant intracranial pressure drop resulting from cerebral dehydration.

Five cases of traumatic intracavernous carotid aneurysm are presented. All of the patients were young men with a history of severe head injury. The clinical manifestations were massive epistaxis and an ipsilateral cavernous sinus syndrome. The diagnosis was made correctly by carotid angiography. All of the patients developed another episode of massive epistaxis after admission. Emergency trapping of the internal carotid artery was performed. An urgent rescue method was used in one of our patients to prevent exsanguination before definitive surgical treatment. One patient died of exsanguination in spite of emergency ligation of the internal carotid artery. In the other four patients, no epistaxis was experienced after the operation.