Traumatic acute subdural hygroma mimicking acute subdural hematoma.

Subdural hygroma is a frequent delayed complication of head trauma. Most hygromas are clinically 'silent' and a few cases have shown slow deterioration in the chronic stage. We report a case of subdural hygroma showing unique radiological findings and rapid deterioration. A 74-years-old female presented with a mild headache and consciousness disturbance after head injury. Computed tomography showed a midline shift as a result of two components piling up in the subdural space; the outer components showed low density, the inner components high density. Magnetic resonance imaging demonstrated that these two subdural components were subdural hygroma and subarachnoid hematoma. Simple burr hole irrigation, rather than large craniotomy, was thought to be more appropriate treatment to reduce the mass effect. Simple burr hole irrigation was performed to remove the subdural hygroma and the patient showed an excellent recovery. Careful examination of the radiological findings prevented an unnecessary procedure in this case. A possible mechanism of this phenomenon is discussed.     

Arterial embolization as preoperative treatment for pulmonary aspergillosis with hemoptysis

Pulmonary aspergillosis associated with old tuberculosis is generally resistant to treatment. Thus, if patients are treated only with conservative therapy, their condition continues to deteriorate due to repetitive hemoptysis, and may even become critical. Surgical treatment is required for these patients; however, it is extremely difficult to resect the lesion due to severe adhesions to the chest wall and vascular proliferation surrounding the lesion. We performed preoperative arterial embolization, achieving good results in three patients with hemoptysis caused by pulmonary aspergillosis. The feeding arteries were embolized using microcoils and/or gelatin sponges, and a lobectomy was safely carried out in all patients. We concluded that preoperative arterial embolization is a safe and effective technique to prevent massive hemorrhage occurring at the time of surgery. This work was presented at the 11th Annual Meeting of the Japanese Association for Chest Surgery, held in Kyoto, Japan, May 13–14, 1994     

Histamine metabolism in the nasal tissue of human and nasal hypersensitive guinea-pig

Histamine (HA) is the most important mediator of nasal allergy and nasal hypersensitivity. To investigate HA metabolism, HA content and activities of its synthetic enzyme, histidine decarboxylase (HDC) and degrading enzymes, histamine-N-methyltransferase (HMT) and diamine oxidase (DAO) in nasal mucosa of human and toluene diisocyanate (TDI) sensitized guinea-pigs were measured. In human nasal mucosa and nasal polyps, HA content and HDC activity were 80-200 nmol/g tissue, 20-30 fmol/min/mg protein respectively. Among two degrading enzymes, HMT activity was 20-200 times higher than that of DAO. In the nasal mucosa of guinea-pigs, HA content was significantly increased by TDI sensitization, and was decreased immediately after TDI provocation. In 24 hours after provocation, HA content recovered to 80% of pre-provocation level. HDC activity increased by TDI sensitization significantly. Though HMT activity increased slightly by TDI sensitization and provocation, DAO activity was unchanged. The data suggest that, increase in turnover rate of HA is present in allergic nasal mucosa.     

Histometric analysis of the distal pancreas in pancreatic head cancer

To clarify the histological status of the pancreas tail after pancreatoduodenectomy (PD), fibrosis, islets of Langerhans, and A, B, and D cells were examined histometrically in surgical cases of pancreatic cancer. The same investigations were also performed during an autopsy examination of the pancreas tail of survivors of surgery who had received either PD or total pancreatectomy with segmental autotransplantation (SAT). In the surgical cases, fibrosis and the islet percentage compared with nonpancreatic cancer cases were significantly higher while the B cell ratio was significantly lower. In addition, in pancreatic cancer patients, the fibrosis and islet ratio in the group with a blocked pancreatic duct were higher while the B cell ratio was lower than in the group with an open pancreatic duct. A direct relationship between the islet ratio and the degree of fibrosis, and an inverse relationship between the B cell ratio and the degree of fibrosis, were thus found. From the autopsy cases, the fibrosis progressed and the islet ratio increased following PD, but after SAT only the islet ratio increased compared to the time of surgery. The progression of fibrosis after PD thus suggests the presence of some problems in both the surgical method and postoperative management.     

Comparison of [I]metaiodobenzylguanidine kinetics with heart rate variability and plasma norepinephrine level

Background. [¹²³I]Metaiodobenzylguanidine (MIBG) imaging has been used to assess cardiac sympathetic nerve abnormalities. We evaluated the clinical significance of myocardial MIBG imaging as a measure of cardiac sympathetic nervous system function by comparing it to heart rate variability and plasma norepinephrine level.Methods and Results. In 211 subjects, we analyzed heart rate variability with 24-hour electrocardiography, performed scintigraphy with MIBG, and measured plasma norepinephrine levels. Time and frequency domain measures of heart rate variability were calculated with the Marquette heart rate variability program (Marquette Electronics, Milwaukee, Wis.). Early and late myocardial MIBG uptakes were measured at 15 and 150 minutes after injection, respectively. MIBG clearance rate from the heart and heart-to-lung and heart-to-mediastinum ratios of MIBG activities were calculated. On the whole, heart rate variability, including low-frequency power, correlated positively, but modestly so, with late MIBG uptake and negatively with MIBG clearance rate. The plasma norepinephrine level correlated negatively with late MIBG uptake and with heart rate variability, including low-frequency power, and positively with MIBG clearance rate. Similar correlations were also observed in patient subgroups with coronary artery disease, diabetes mellitus, and renal failure, but these correlations were weak (R² < 0.5).Conclusions. Increased cardiac sympathetic nervous system activity may be associated with increased myocardial MIBG clearance and decreased heart rate variability, including low-frequency power. Because these associations were not strong, however, the combination of heart rate variability with MIBG may allow an interactive assessment of the cardiac autonomic nervous system.     

Repair and reconstruction of peripheral nerve injuries

Axonal regeneration after transection is a complex biological process. It is not merely a process of tissue repair, but rather of cellular repair of a large number of nerve cells. Regeneration involves restoration of the original morphology of each single cell, rather than proliferation. Techniques in microneurosurgical reconstruction of peripheral nerve injuries have improved over the last two decades, with subsequent improvement in functional results. Nerve autografts are now routinely used to guide the regrowth of the proximal nerves to distal nerve segments. However, the limited source of expendable cutaneous nerves restricts the use of nerve grafting techniques and is associated with significant morbidity. With extensive injuries there is an insufficient quantity of nerve autograft material to facilitate optimal repair. In future, the use of artificial conduits or nerve allografts could provide a limitless source of material to reconstruct otherwise irreparable traumatic nerve injuries. Establishment of appropriate strategies to suppress host-immune reaction or donor antigenicity would facilitate clinical allogeneic nerve transplantation. Guest lecture presented at the 69th Annual Meeting of the Japanese Orthopaedic Association in Tokyo on April 13, 1996.     

Dendritic Cells Coinjected with Tumor Cells Treated with an Anticancer Drug to Induce Tumor Rejection

Purpose: We examined whether bone marrow-derived dendritic cells (DCs) could induce antitumor immunity when a chemotherapeutic drug was added. Methods: CT26 (a murine colon cancer cell line syngeneic with BALB/c) and CT26-bearing mice were treated with mitomycin C (MMC) intraperitoneally (i.p.). Next, mice immunized with a coinjection of DCs and MMC-treated CT26 (i.p.) were given an intradermal inoculation of CT26. Finally, CT26-bearing mice were treated with MMC (i.p.) with or without DCs, given peritumorally. Results: Although the inoculated tumor was not rejected in the control mice, CT26 was rejected in 50% of the mice injected with MMC alone. Apoptosis was observed in the MMC-treated CT26 cells in vitro and in vivo. Immunization with DCs and apoptotic CT26 cells, but not with apoptotic CT26 alone, gave protection against tumor challenge in 7 of 13 mice. A significantly higher level of cytotoxic T-cell activity and interferon-γ production was seen in the protected mice. When MMC (i.p.) treatment was followed by peritumoral DC injection in the CT26-bearing mice, remarkable therapeutic effects were observed. Conclusion: DCs can collaborate with chemotherapy-induced apoptotic tumor cells and elicit improved antitumor immunity, probably through the acquisition of tumor-associated antigens from apoptotic tumor cells. Received: January 7, 2002 / Accepted: September 3, 2002 Acknowledgments. We thank Dr. Kazuo Kinoshita for his useful advice on using flow cytometry. This research was partly supported by the Ministry of Education, Culture, Sports, Science and Technology (No. 11671160). Reprint requests to: S. Yamasaki     

Tumor Response to Neoadjuvant Chemotherapy Correlates with the Expression of P-Glycoprotein and PCNA but Not GST-π in the Tumor Cells of Cervical Carcinoma

Objective.To identify the clinicopathological and chemoresistant factors predicting the response to neoadjuvant chemotherapy and the patient prognosis in high-risk cervical carcinomas.Methods.We retrospectively reviewed 47 patients with locally advanced or bulky cervical carcinoma treated with two courses of intraarterial infusion of cisplatin, doxorubicin, mitomycin C, and 5-fluorouracil (5-FU), followed by radical hysterectomy at our hospital between 1988 and 1995. Expressions of the chemoresistance-related proteins, such as P-glycoprotein, glutathioneS-transferase π (GST-π), and proliferating cell nuclear antigen (PCNA) in the tumor cells, were examined by immunohistochemistry using pretreatment biopsy specimens. These results were compared with the chemotherapeutic response, which was evaluated by magnetic resonance imaging (MRI) and histopathology. Outcome of the patients was also studied.Results.Chemotherapeutic effect of either complete (CR) or partial (PR) response on MRI was obtained in 36 of the 47 (86%) patients. Poor response to chemotherapy was significantly correlated with P-glycoprotein expression (P< 0.005) and low PCNA labeling (P< 0.05), but not GST-π expression in the tumor cells. Independent prognostic factors for patient survival were parametrial involvement and lymph node metastasis. Neither the expression of GST-π nor PCNA was correlated with the patient survival.Conclusion.Assessment of the expression of P-glycoprotein and PCNA is potentially useful for the prediction of tumor response to neoadjuvant chemotherapy for cervical carcinomas.