Biomedical subjects
Publications and source records attributed to H Kuba.
The authors report two unusual cases in which a malignant astrocytoma developed at the site of the excision of an earlier medulloblastoma. While the precise etiology of these astrocytic tumours was unproven, theories of the origins of the second tumours, particularly in relation to the basic nature of medulloblastomas, are discussed.
Ventriculoperitoneal (VP) shunt placement in patients with aqueductal stenosis has recently been reported as a cause of pneumocephalus. We report on a patient with pneumocephalus associated with aqueductal stenosis treated by VP shunting. A 29-year-old woman who had undergone a shunt operation for aqueductal stenosis 7 years previously sustained a whiplash injury in a minor traffic accident. Computed tomography (CT) revealed massive subdural pneumocephalus, and three-dimensional reconstructions of CT images clearly demonstrated defects in the skull base overlying the ethmoid sinuses. Both endoscopic III ventriculostomy and placement of external ventricular drainage were came free of symptoms and rhinorrhea ceased. Three-dimensionally reconstructed CT images were useful in detecting the extent of the patient's skull base defect. III Ventriculostomy was not effective in this case. Direct closure of the skull base by craniotomy was not necessary, and a programmable valve system was effective in preventing recurrence of either pneumocephalus or rhinorrhea.
We treated a patient whose unusual recurrent germinoma illustrates the diagnostic value of measuring human chorionic gonadotropin beta subunit (HCG-beta) in cerebrospinal fluid (CSF) and serum. A 25-year-old man with a suprasellar germinoma and ventricular dissemination was treated successfully with systemic chemotherapy and cranial irradiation. Six years later he developed progressive numbness and weakness in both upper extremities. Magnetic resonance imaging (MRI) disclosed an intramedullary spinal cord tumor in the cervical region. The CSF concentration of HCG-beta was elevated and exceeded that in serum. After completion of systemic chemotherapy and spinal irradiation, symptoms subsided and the tumor was no longer evident on MRI. Based on the patient's history and the rapid response of the tumor to treatment, the spinal cord tumor was considered a metastatic intramedullary spinal germinoma representing CSF dissemination via the central canal.
The usefulness of the infratemporal fossa type C approach is reported through a presentation of a case of clival chordoma, which was successfully treated by this approach. Although it is complicated and includes some demerits, this approach gives a shorter and wider access to mid-skull base pathology than other approaches. Among the demerits, deformity of the temporal region caused by extensive drilling of the bone could be minimized by cosmetic mastoidectomy, which was first applied during this approach by the authors. The surgical anatomy for this approach is demonstrated using a cadaver specimen.
We herein describe a patient with mediastinal lymph node metastases which occurred after both a primary sigmoid colon cancer and metachronous ovarian metastasis had been resected. The most likely route of metastases to the mediastinum in this case is the paravertebral venous plexus probably connected to the ovarian metastasis, or so-called remetastasis. This case illustrates that the mediastinum is thus a possible metastatic site in patients with colon cancer. Surgeons should therefore pay attention to the mediastinum as well as the lung fields when checking chest X-ray films during a follow-up of patients after a resection of colon cancer.
We describe the usefulness of three-dimensional Fourier transformation-constructive interference in steady-state (CISS) imaging and diffusion-weighted imaging (DWI) in the pre- and postoperative magnetic resonance imaging evaluation of intracranial epidermoid tumors. Two surgically proven epidermoid tumors in the cerebellopontine (CP) angle were not identified in conventional T1- and T2-weighted images because of a signal intensity similar to that of cerebrospinal fluid (CSF). CISS images clearly demonstrated displacement of the cranial nerves and a shift caused by a lesion in the cistern, but the signal intensity of the tumor by CISS was not sufficiently different from that of CSF to demonstrate the tumor directly. Using DWI, the tumor in the cistern was shown clearly by its increased signal intensity. Together, CISS and DWI compensated for each other's disadvantages, and this combination was useful in guiding surgical treatment of epidermoid tumors in the CP cistern.
Carbamazepine (CBZ) is a drug which can induce the syndrome of inappropriate antidiuretic hormone (SIADH). Until 1980's, there were reports regarding CBZ-induced SIADH, but it is rarely reported these days. We here report two cases of CBZ-induced SIADH. Hyponatremia in these cases was rapidly improved by withdrawal of administration of CBZ. According to the previous reports, the rate of hyponatremia in patients receiving CBZ is not small. It ranges from 48% to 31%. As CBZ is frequently used for patients with epilepsy and neuralgia, not only their blood CBZ concentration but also their serum Na level should be monitored.
A 49-year-old woman, with a two-year-history of multiple screlosis (MS), noticed postural dizziness, intractable hiccups and vomiting. On admission, she had mild quadriparesis, hypesthesia below the C5 level, and a girdle sensation at the T5 and L1 levels. A CSF examination showed slight increases in the protein level (48 mg/dl) and cell count (7/mm3). Brain MRI demonstrated no obvious lesion in the medulla oblongata. The head-up-tilting test showed a decrease in the blood pressure from 105/63 mmHg to 70/55 mmHg. The pulse rate, however, increased from 57/min to 72/min. The cold pressure test also revealed a mild impairement in her blood pressure response. The R-R interval variation (coefficient of variation: CVRR) during normal breathing was 2.58 (normal: > 1.66). The valsalva ratio was 1.84 (normal: 1.4-2.0). The Aschner eye-ball pressure test, the blood pressure response to the injection of epinephrine, and the sweating response to the injection of acetylcholine were all normal. She was thus administered domperidone and chlorpromazine. Only domperidone effectively improved the nausea and vomiting. All symptoms, including orthostatic hypotension, hiccups and vomiting, disappeared about one month after admission. The remission of her symptoms was considered to reflect the natural course of MS. The results of autonomic nervous system function tests and her clinical features suggest that an irritable lesion in the medullary tegmentum, including the nucleus tractus solitarii, most likely caused her symptoms. The above findings indicate that autonomic symptoms, such as orthstatic hypotension, hiccups and vomiting, may sometimes be the only symptoms observed in a relapse of MS.
Pseudocyst of the pancreas is sometimes difficult to distinguish from mucinous cystic neoplasm of the pancreas. A 37-year-old asymptomatic Japanese man was diagnosed with hypertension. He had a 20-years history of habitual drinking of alcohol, but no history of pancreatitis or abdominal trauma. During examinations to ascertain the cause of hypertension, ultrasonography and computed tomography incidentally demonstrated a huge cyst in the head of the pancreas. Laboratory data were within normal limits, including serum levels of amylase, carcinoembryonic antigen, and carbohydrate antigen 19-9. Imaging studies showed a huge unilocular cyst, measuring 7 cm, in the head-to-body of the pancreas, and two small unilocular cysts, measuring 1.4 and 1.5 cm, in the tail and head of the pancreas, respectively. A mural nodule was suspected in the largest cyst. Endoscopic retrograde cholangiopancreatography demonstrated communication of the main pancreatic duct with the two small cysts in the head and tail of the pancreas but not with the huge cyst. There were no ductal changes suggesting chronic pancreatitis. Laparotomy was performed under the tentative diagnosis of potentially malignant mucinous cystic neoplasms of the pancreas. However, inflammatory adhesion was dense around the pancreas and the mural nodule suspected preoperatively was found to be sludge aggregates in a pseudocyst. The diagnosis of an intraoperative frozen section of the cyst wall was pseudocyst of the pancreas. Cystojejunostomy was performed. We report this case because the preoperative diagnosis was mucinous cystic neoplasm of the pancreas, but the diagnosis changed with careful intraoperative examinations, to pseudocyst of the pancreas. We discuss the differential diagnosis of the two conditions.
Lactic acidosis due to thiamine deficiency is known to complicate chemotherapy and radiotherapy treatment of malignant extracranial tumors, but to the authors' knowledge, this complication has not been reported in patients treated for malignant brain tumors. They report three such cases, demonstrating that this complication can occur during treatment of brain tumors. In all patients, consciousness levels deteriorated within 1 to 2 days. Serum lactic acid levels increased to concentrations between 62 and 96.7 mg/dl, resulting in severe metabolic acidosis. A low blood thiamine level (9 ng/ml) was demonstrated at the onset in one case, and high-dose thiamine infusions dramatically improved lactic acidemia as well as impairment of consciousness in two cases. In the other case, hydrocephalus was suspected initially, resulting in a delay in thiamine supplementation. Clinical differentiation of this form of lactic acidosis from hydrocephalus or tumor progression can be very difficult in a patient undergoing treatment for a malignant brain tumor. Demand for thiamine is thought to be increased in patients with malignant brain tumors, and supplemental thiamine during treatment is necessary to prevent lactic acidosis. When this complication occurs, immediate treatment with sufficient thiamine is essential, together with normalization of pH by using sodium bicarbonate. With timely intervention, the level of consciousness can recover to the preacidotic state with no new neurological deficits.