Intracranial Diseases Research Articles

Significance of Dexamethasone Suppression Test in Patients with Stroke

The purpose of this study was to evaluate the effect of stroke on hypothalamic-pituitary axis using dexamethasone suppression test. The effects were evaluated according to age, sex, type, size, and lesion site of stroke. These tests were performed in 62 patients with stroke(cerebral infarction, 42 cases : intracerebral hemorrage, 20 cases) and 21 disabled controlled patients without intracranial diseases at Yeungnam University Hospital from June 1992 to June 1993. The results summarized as follows. 1. Cerebral infarction showed significantly higher frequency of DST non-suppression in stroke patients than control(p

Carbogen Breathing in Patients with Glioblastoma Multiforme Submitted to Radiotherapy Assessment of gas Exchange Parameters

It has been reported that carbogen breathing yields a remarkable increase of radiosensitivity in murine tumour models. Hence, application of carbogen might be promising in radiotherapy of human tumours. We describe a method to increase arterial oxygenation and to ensure stability of O2 and CO2 during carbogen breathing in patients with malignant disease. We measured in 6 patients with histologically proven intracranial glioblastoma multiforme arterial blood gases, inspired and expired gas concentrations and vital signs either baseline and during carbogen breathing. The highest values of arterial oxygenation were achieved after 10 min of carbogen breathing and they remained stable up to 15 min. In none of our patients was N2 wash-out from the lungs completed in 15 min of carbogen breathing. In conclusion, carbogen breathing increased arterial oxygenation in patients with intracranial malignant diseases. The system used is reliable and of practical use. Monitoring of expired gas concentrations is highly recommended.

In vivo tissue characterization of human brain by chisquares parameter maps: Multiparameter proton T2-relaxation analysis

The heterogeneous proton MR relaxation decay process in human brain has been investigated by performing region-of-interest and pixel-by-pixel calculations on the multiecho MR images with different repetition times (TR) of human brains using a clinical 1.5-T whole-body superconducting MR scanner. Based on the monoexponential, biexponential, and continuous gaussian distribution relaxation models, first-order proton relaxation parameters (proton density, T 1 and T 2) and higher-order transverse proton relaxation parameters ( T 2-long, T 2-short, T 2-long fraction, T 2-average, and T 2-distribution width) were calculated. On the basis of an F test ( p < .01), the statistical significance of the higher-order (biexponential and distribution) fits over the monoexponential fit was evaluated. Here, a significant improvement in the biexponential fit was found for some of the regions containing the ventricular cerebrospinal fluid (CSF) ( T 2-long = 2780 ± 570 ms; T 2-short = 159 ± 42 ms; T 2-long fraction = 0.51 ± 0.08 ms) due to the partial volume effect but not for most of the white matter (WM). On the other hand, an improvement of fit to WM was obtained when distribution ( T 2-average = 80 ± 8 ms; T 2-distribution half-width = 21 ± 4 ms) as opposed to monoexponential ( T 2 = 89 ± 10 ms) fit was used. As internal controls, tubes of CuSO 4 solution ( T 2 = 1293 ± 128 ms) and agarose gel ( T 2 = 111 ± 10 ms) which have similar T 2 values as the CSF and WM of the brain, respectively, were attached to the human head and imaged concomitantly. No significance improvements in either the biexponential or distribution fits over the monoexponential fit were found for all the controls. In addition to the first-order and higher-order relaxation parameter maps, the monoexponential chisquares, as well as the chisquares ratio (chisquares of the monoexponential fit divided by that of the higher-order fit), maps were also generated. Unlike the higher-order T 2-relaxation parameter maps, the chisquares parameter maps required no selection of any predetermined statistical confidence level. Therefore, these chisquares parameter maps provided a somewhat nonsubjective spatial prolife of the heterogeneous transverse relaxation process in the brain. Our results led us to propose that the use of chisquares parameter maps, together with the first-and higher-order relaxation parameter maps, may further improve the in vivo tissue characterization capability of MRI in future clinical diagnosis and staging of intracranial diseases.

Plasma natriuretic factor(s) in patients with intracranial disease, renal salt wasting and hyperuricosuria

To test our hypothesis that a circulating factor(s) may be causing the renal salt and urate wasting in patients (pts) with intracranial diseases, we exposed rats to the plasma of these patients and studied sodium and lithium transport. We selected 21 neurosurgical pts, 13 of whom had increased fractional excretion (FE) of urate, and 14 age and sex-matched controls. Plasma from pts and controls were injected IP (0.5 mL) and infused, 0.2 ml prime and 1.8 mL at 0.01 mL/min, to Sprague Dawley rats anesthetized with Inactin. Renal transport of sodium (Na), lithium (Li) and potassium (K) was determined. There were higher mean ± SEM for FENa, 0.59 ± 0.07% vs 0.29 ± 0.05%, P < 0.01, FELi, 36.6 ± 1.9% vs 24.0 ± 1.6%, P < 0.001 and K excretion rates, 1.69 ± 0.13 vs 1.31 ± 0.09 μmol/min, p < 0.02, in rats infused with plasma of pts as compared to controls, respectively. FENa decreased with increasing dilution of plasma of 2 pts with ICD. There was no difference in mean weight of rats, blood pressure, urine flow rate or inulin clearance between pts and controls. These data suggest that pts with ICD have a plasma factor(s) which decreases net Na, Li and K reabsorption.

Abnormal Urate Transport in Patients With Intracranial Disease

Based on our demonstration of a high incidence of hypouricemia, tubular urate transport abnormality, and cerebral atrophy in patients with acquired immunodeficiency syndrome (AIDS), we performed prospective renal clearance studies in 29 consecutive neurosurgical patients with intracranial diseases of multiple etiologies to test our hypothesis that patients with intracranial disorders had defective tubular urate transport. Similar studies were performed in 21 age-matched controls. None of the subjects had serum creatinine greater than 123.8 mumol/L (1.4 mg/dL), sickle cell or liver diseases, or received intravenous fluid or uricosuric drugs at the time of study. Seven patients had no surgical procedures, 12 were studied after a neurosurgical procedure, and 10 had preoperative and postoperative studies. Ten had more than one postoperative study. Twelve had 24-hour urine collections. We found that 18 of 29 patients had elevated fractional excretion (FE) of urate greater than 10%. There was no difference in preoperative and postoperative FE urate by nonpaired t test for all patients and by paired t test in the 10 patients who had preoperative and postoperative studies performed. Seven patients had hypouricemia, defined as serum urate less than or equal to 0.18 mmol/L (3 mg/dL). Only one had hyponatremia (serum sodium less than 130 mmol/L). Urate excretion averaged 3.6 +/- 0.32 mmol (603 +/- 52.7 mg)/24 h, suggesting that the hypouricemia was not due to decreased urate production. None of the medications or surgical procedures could be considered to have caused the urate transport abnormality, nor was it associated with any specific intracranial location or type of disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Erfahrungen mit Lichtblitz-evozierten visuellen Potentialen bei bewußtseinsgetrübten Patienten auf der neurologischen Intensivstation

Evoked potential monitoring has become a widely used procedure in the evaluation of stuporous patients on neurological intensive care units. Currently BAEP and SEP are preferentially employed. VEP monitoring is a relatively uncommon procedure, because late evoked potentials tend to be relatively unstable, varying in amplitude to a moderate extend from changes of temperature, drugs, attention and the level of consciousness. A valuable approach of VEP monitoring on intensive care units are structures of the visual system at risk in vascular disease of the vertebrobasilar system or during evaluated intracranial pressure (EIP). This study uses the data of 20 stuporous patients presenting with either intracranial mass lesions or vascular diseases of the vertebrobasilar system and 20 control persons. Light emitting diode (LED)-VEP are compared with checkerboard stimulation in control persons using the technique of cross-correlation. The comparison of the control group with patients using LED-VEP allows definition of limits for normal variation as a base for identification of significant changes. Despite methodical restrictions of LED-VEP, our results are in favour of serial studies in patients with EIP. There are no corresponding findings in LED-VEP and vascular lesions of the retrochiasmatic visual system.

201TI SPECT FOR EVALUATION OF BRAIN TUMORS AS COMPARED WITH 123I-IMP SPECT AND 18F-FDG PET

Clinical usefulness of 201T1 SPECT for evaluation of brain tumors was studied in comparison with 123I-IMP SPECT and 18F-FDG PET.201T1 SPECT and 123IMP SPECT were performed in 73 patients with brain neoplasm (group 1) and 15 patients with non-tumor cerebral diseases (group 2). Among them, 31 patients in group 1 and 5 patients in group 2 received 18F-FDG PET. SPECT was done with a ring type machine (HEADTOME SET011) and PET with a neuro PET (PCT H1).Forty-eight of 73 (65.8%) patients in group 1 showed increased accumulation of 201T1 in tumor site, whereas only 9 (12.3%) patients showed increased radioactivity of 123I-IMP in the lesion. Eighteen of 31 (58.1%) patients with neoplasm demonstrated increased regional cerebral metabolic rate of glucose (rCMRgl) in the lesion. Only two out of 15 (13.3%) patients with non-tumor lesion demonstrated increased accumulation of 201T1. None of them showed accumulation of 123I-IMP or increased rCMRgl. Patients with malignant neoplasm demonstrated higher uptake of 201T1 in the lesion than those with benign neoplasm or non-tumor lesions. Post-therapeutic patients with glioblastoma or metastatic tumors showed lower 201T1 uptake than before therapy. Superimposed images of both 201T1 and 123I-IMP resemble rCMRgl functional images, suggesting increased 201T1 radioactivity in viable tumor tissue with decreased radioactivity in surrounding areas.201T1 SPECT is useful for diagnosis of brain tumors and evaluation of effectiveness of therapy or evidence of residual tumor tissue. It may differentiate malignant tumors from benign tumors or non-tumor intracranial diseases including radiation injury and detect tumor recurrence earlier.

Quantitation of blood‐brain barrier defect by magnetic resonance imaging and gadolinium‐DTPA in patients with multiple sclerosis and brain tumors

In this study quantitation of the degree of deficiency of the blood-brain barrier (BBB) in patients with multiple sclerosis or brain tumors, by using MRI, is shown to be possible. As a measure of permeability of the BBB to Gadolinium-DTPA (Gd-DTPA) the flux per unit of distribution volume per unit of brain mass was used. This quantity was found by introducing the longitudinal relaxation rate (R1) as a measure of concentration of Gd-DTPA in the brain tissue in the mathematical model for the transcapillary transport over the BBB. High accordance between the observed data points and the model was found, and the results were comparable to results obtained from similar studies using positron emission tomography. The improved possibility of quantitating the defect of the BBB by MRI may give new information about pathogenesis or etiology, and leads to improved methods in monitoring the efficacy of treatments in intracranial diseases.

New technical and clinical aspects for cerebrovascular applications of ultrasound methods

Various Doppler-ultrasound methods have been established for the evaluation of both extracranial and intracranial vascular diseases. The validity of the presently used techniques and new aspects of work in progress are demonstrated and discussed in detail because of the increasing clinical interest in detailed vascular information for prospective follow-up investigation.

Hemifacial Spasm in Infancy

Three infants presented with the onset of hemifacial spasm after birth and at the age of 10 months. One patient was found to have occlusion of the straight sinus and large collateral veins at the base of the brain, presumably due to venous sinus thrombosis, supporting the concept of vascular compression of the facial nerve at its exit from the brain stem as a mechanism for the production of hemifacial spasm. The other patients each had an intrinsic mass compressing the fourth ventricle, located in the lower pons and extending into the cerebellar vermis and right cerebellar peduncle in one; in the other patient, the mass involved the cerebellar vermis and right middle cerebellar peduncle alone. These patients widen the etiologic spectrum of the syndrome and show that serious intracranial diseases may underlie hemifacial spasm in infancy.

Headache in childhood.

Migraine in children is diagnosed in presence of paroxystic episodes of headache which recur with free intervals, provided intracranial diseases are excluded. Pathogenesis of this disorder is unclear; migraine with and migraine without aura may be different entities. Many factors can precipitate a migraine attack. In school age, psychologic stress is the commonest factor. Main characteristics of attacks in children are headache, which may be hemicranial; nausea and vomiting, abdominal pain, paraesthesiae. Scotomata are not very common in the pediatric age. In some cases, migraine attacks are complicated by sensory or motor symptoms (paraesthesiae, paresis), usually at one hemisoma. In the basilar artery migraine syndrome, features of brain-stem dysfunction predominate. In a few patients a migraine attack presents itself as an acute confusional state. In migraine, EEG abnormalities are frequent (predominance of diffuse or focal slowing). In some cases a CSF pleocytosis is found after an attack of complex migraine. Prognosis is good. Preventive treatment is necessary if the attacks are severe and if they cannot be relieved by rest or sleep. Symptomatic headaches may be produced by a variety of causes. Rarely, it is secondary to increased intracranial pressure. In the great majority of cases recurrent headache is due to migraine. Usually, clinical data are sufficient for diagnosis, though in some cases the diagnosis is difficult and it is necessary to perform laboratory examinations in order to exclude symptomatic headache.

Indications for the use of Gd-DTPA in MRI of the central nervous system. Experiences in patients with cerebral and spinal diseases.

A total of 209 intracranial and spinal diseases were evaluated before and after administration of the paramagnetic contrast agent Gd-DTPA. The results justify the use of Gd-DTPA in intracranial and spinal tumors for better visualization of location and extent of a lesion and for better tissue differentiation. In inflammatory diseases Gd-DTPA allows the differentiation between active and chronic lesions.

Occasional elevation of immunoreactive LRH in plasma and cerebrospinal fluid in acute intracranial diseases.

Occasional elevation of immunoreactive LRH in plasma and cerebrospinal fluid in acute intracranial diseases.

Non-traumatic brain abscess. Epidemiology, clinical symptoms and therapeutic results.

Two groups of patients with non-traumatic focal intracranial suppurative diseases were studied retrospectively to illustrate epidemiology, clinical symptoms and therapeutic results. The first group consists of 87 patients treated for brain abscess in the Department of Neurosurgery in Lund. During the 36-year period investigated (1947-1982) marked epidemiological changes occurred. Thus otogenic abscesses, constituting 33% of the cases below the age of 30 during the first 12 years of the study, virtually disappeared. During the third 12-year period of this study a marked increase in the number of abscesses was noted. The increase was caused particularly by the number of cryptogenic abscesses amounting to 51% of the material during 1971-1982. The second group of patients consists of all patients with pre- or post-mortem diagnosed brain abscess in the city of Malmö during 1960-1981. Since during this period 85% of all persons who died in this city were subjected to post-mortem examination this material offers a unique possibility of epidemiological studies. The combined study of these two groups of patients lends no support to the view that a real increase in the number of brain abscesses has occurred. We conclude that in patients with cryptogenic brain abscess the clinical symptoms do not usually indicate the presence of an infectious disease. In the majority of these patients a correct diagnosis has presumably not been obtained until the last decade. Furthermore, the investigation confirms the view that a mortality below 10% is nowadays feasible in unselected cases of brain abscess.

Immunoreactive LHRH in cerebrospinal fluid: the clinical significance in intracranial diseases.

Cerebrospinal fluid (CSF) and plasma levels of luteinizing hormone-releasing hormone (LHRH) were measured by RIA in 46 patients with acute intracranial diseases, ie, cerebral bleeding (group A), cerebral thrombosis (B), head injury (C) and meningitis (D), and the results were compared to those obtained in 21 patients with non-intracranial diseases (group E; control). Immunoreactive LHRH concentrations in CSF (CSF IR-LHRH) of 8 postmenopausal women in group E ranged 1.3 to 6.1 (mean +/- SE: 3.1 +/- 0.6) pg/ml, and those of 5 other women and 8 men with group E ranged 1.0 to 5.6 (3.6 +/- 0.4)pg/ml. In 7 out of 15 patients in group A(7/15), CSF IR-LHRH were above the levels seen in group E. In group B, C and D, CSF IR-LHRH were above the control levels in 9/15, 1/9, 3/7, respectively. The changes in plasma LHRH were not clear in postmenopausal patients in groups A and B. Plasma IR-LHRH in other women and men in group A were above the control levels in 2 out of 9 patients (2/9). Those in groups B, C and D were above the control levels in 3/8, 1/9, 2/7, respectively. Moreover, both plasma and CSF IR-LHRH of 13 patients in group A or B in chronic stage were within the control ranges. In cases observed following the time course, the occasionally increased IR-LHRH in plasma and CSF tended to decrease following the abatement of the diseases.(ABSTRACT TRUNCATED AT 250 WORDS)

Transcranial Doppler sonography: a new approach in the non-invasive diagnosis of intracranial brain artery disease.

56 stroke patients were investigated with the new non-invasive method of transcranial Doppler sonography (TCD), operating with a range-gated pulsed 2 MHz Doppler. In 28.6% of the 56 patients TCD provided additional information about the status of the basal cerebral arteries. The results of the TCD investigation were confirmed by angiography in 14 patients. This result indicates that TCD is a valuable non-invasive method of high accuracy for the detection of intracranial brain artery diseases and collateral flow mechanisms.

Prenatal and perinatal factors associated with brain disorders.

In April 1985, a report entitled "Prenatal and Perinatal Factors Associated with Brain Disorders" was published by the National Institutes of Child Health and Human Development and the National Institute of Neurological and Communicative Disorders and Stroke. A panel of ten individuals completed the report documenting the knowledge and the complexities of what is known with respect to brain damage that may develop before birth or in the neonatal period. It is clear that all stages of fetal and neonatal development influence normal outcome. Although intrapartal period events may explain a significant portion of cerebral palsy, the illness is often linked with confounding factors such as low birth weight and asphyxia. Pure epilepsy or pure mental retardation is rarely associated with intrapartal events. In general, the pathologic lesions seen in the brain may reflect many different fetal insults. The same clinical event such as asphyxia may result in varied intracranial diseases, which effects may depend on when the clinical events occurred.

Clinical Studies of Intracranial Lesions of Disseminated Intravascular Coagulation Syndrome by Computerized Tomography

Six cases of intracranial hemorrhage associated with disseminated intravascular coagulation (DIC) syndrome were reported. Previously, intracranial hemorrhage was said to be much less frequent than cerebral infarction in DIC. However, intracranial hemorrhage was demonstrated in all of the 6 cases suffering from DIC who received computerized tomographic scanning. The high incidence of intracranial hemorrhage in this series was attributed to weakness of vascular wall which possibly resulted from primary intracranial diseases. Primary intracranial diseases existed in 3 cases: cerebrovascular disease, head injury, and meningitis. In complication with multiple organ failure, all of these patients expired. Aggressive treatment did not influence the outcome. Treatment of such cases should be early diagnosis and treatment of primary disease, which is likely to be the cause of DIC.

Effect of prostacyclin and adenosine triphosphate on vasospasm of canine basilar artery

Cerebral vasospasm is one of the most important factors influencing morbidity and mortality of intracranial operations or diseases. Platelet aggregation and adhesion is increased in spastic vessels. Degredation of platelets liberates mediators, which in turn increase vasospasm, thus creating a vicious cycle. Healthy vessels cope with this by increasing the synthesis of prostacyclin. The purpose of this study was to increase experimentally the levels of arterial prostacyclin and adenosine triphosphate (ATP) in animals through intraarterial injection of these substances because they are lower in spastic vessels. Prostacyclin promotes antiaggregation and dilatation, increases blood flow, inhibits thromboxane A 2, and prevents synthesis of angiotensin II. Most of these effects were done by increasing cyclic adenosine monophosphate (cAMP). After injecting autogenous blood into the cisterna magna of male dogs, both the acute and chronic phases of vasospasm and the degenerative changes in the arterial wall were observed. Injecting ATP increased the severity of vasospasm. During vasospasm it was found that when prostacyclin is used intraarterially, vasodilatation began, but degeneration of the arterial wall could not be prevented. In the group of animals in which both ATP and prostacyclin were used, there was no degeneration of the arterial wall and the basilar artery was seen to be normal when viewed under the electron microscope.

Granulomatous diseases of the CNS as demonstrated by computerized tomography

The CT findings in 32 patients with pathological conditions characterized by granulomatous disorders are reviewed. The characteristic CT finding in caseating granuloma due to tuberculous disease is a nodular enhancing lesion with a central hypodense region. The granulomas representing sarcoidosis show homogeneous enhancing nodular lesions. The granulomas due to cryptococcal fungal disease showed ring pattern with large central hypodense region which represented cyst formation. In certain vasculitides which affected the CNS and had pathological evidence of granuloma formation, CT showed nodular enhancing lesions. Based upon the CT findings, it was not possible to differentiate these nodular enhancing lesions which represented granulomatous disease from other intracranial diseases, i.e. abscesses, neoplasms, multiple sclerosis, gliosis.