Tatsuya Tanikawa

A New Approach to Control Central Deafferentation Pain: Spinal Intrathecal Baclofen

We investigated the short-term effects of an intrathecal bolus injection of baclofen on central pain due to stroke or spinal cord injury. Pain relief was obtained in 64% of the patients. The effects developed 1-2 hours after the injection and continued for 10-24 hours. Both spinal segmental and supraspinal mechanisms may be involved in the production of baclofen-analgesia.

CT-guided stereotactic surgery for evacuation of hypertensive intracerebral hematoma

During the last 3 years, 46 cases of hypertensive intracerebral hemorrhage were treated by CT-guided stereotactic surgery. Our present report is concerned with the evaluation of this procedure in the treatment of hypertensive intracerebral hematoma, in terms of the rate of aspirated hematoma and follow-up study of patients. It is difficult to draw any definite conclusion about the operative indications. CT-guided stereotactic aspiration, however, can be evaluated as a less invasive and more definitive treatment of intracerebral hematoma in the basal ganglia and thalamus.

Single Neuron Analysis of the Human Midbrain Tegmentum

Rostral mesencephalic reticulotomy (RMR) has been performed since 1973 for relief of intractable pain. The target area is in the midbrain reticular formation (MRF) bordering the periaqueductal gray matter at the superior collicular level. The target of RMR is 13--16 mm posterior to the midpoint of the AC-PC line and 5--8 mm below the AC-PC line. The laterality of the target is measured from the center of the aqueduct, ranging 5 to 8 mm from the midline. The rationale for this procedure is based upon the previous findings that the brain stem reticular formation plays a more important role above the spinal cord level than the lateral spinothalamic tract in the central conduction of nociceptive impulse. In the present study, intraoperative single neuron recording was made with tungsten microelectrodes from the human midbrain tegmentum in response to peripheral pinprick stimulation. These nociceptive neurons were classified into three groups in regard to the unit latency from the peripheral pinprick stimulation.

Aspergillotic aneurysm formation of cerebral artery following neurosurgical operation

A rare case of intracranial aspergillotic aneurysm following neurosurgical operation for facial spasm is presented. Severe meningitis had persisted several days prior to the subarachnoid hemorrhage which occurred on 70th postoperative day. Angiography demonstrated a fusiform aneurysm at the peduncular segment of the superior cerebellar artery on the other side of operation. As the repeated cultures of CSF were negative, the pathogenetic factor causing aneurysm formation could not be identified before second operation of aneurysmal resection. Pathological study of the specimen revealed the arterial wall being deeply invaded by aspergillotic hyphae.

Rebleeding of intracranial dissecting aneurysm in the vertebral artery following proximal clipping

We describe a case of rebleeding from an intracranial vertebral dissecting aneurysm following proximal clipping. This case suggests that proximal clipping alone may not be an adequate surgical procedure to prevent rebleeding. Surgical treatment of intracranial dissecting aneurysms in the vertebral artery presenting as subarachnoid haemorrhage. (SAH) is discussed.

Dialysis dysequilibrium syndrome in neurosurgical patients.

Four neurosurgical patients with acute renal failure are presented. Intracranial pressure (ICP), cerebrospinal fluid (CSF) osmolality, and plasma osmolality were measured before, during, and after hemodialysis. There was an increase in ICP during all six hemodialyses performed on these patients. An osmolality gradient was established between the plasma and the CSF during four hemodialyses performed on two patients but not during one hemodialysis on one other patient. Continuous ventricular drainage and ICP monitoring were simple and effective clinical methods to avoid irreversible herniation during hemodialysis in these patients. A review of the literature on, proposed pathogenesis of, and prophylactic possibilities for dialysis dysequilibrium syndrome in neurosurgical patients is presented.

Alterations of Immunoreactive beta-Endorphin in the Third Ventricular Fluid in Response to Electrical Stimulation of the Human Periaqueductal Gray Matter

Immunoreactive beta-endorphin in the third ventricular fluid was measured in response to electrical stimulation of the periaqueductal gray matter in 8 patients with intractable pain during rostral mesencephalic reticulotomy for pain relief. In all patients, marked increase of immunoreactive beta-endorphin was observed. On the other hand, in cases of electrical stimulation of the zona incerta performed during stereoencephalotomy, in 5 patients with involuntary movement, immunoreactive beta-endorphin in the third ventricular fluid did not show any significant change. The authors conclude that the increase of immunoreactive beta-endorphin on electrical stimulation of the periaqueductal gray matter is not a nonspecific response to brain stimulation but a specific response in regard to cerebral localization of endorphins. Direct correlation between pain relief and periaqueductal gray stimulation is also questioned.

A New Apparatus for CT-Guided Stereotactic Surgery

Combining whole-body CT scan with a stereotactic system, the authors have developed and applied clinically an apparatus which readily provides intraoperative CT images, making it possible to confirm the location of the target point and ascertain the intraoperative environment. It takes about 9 s to obtain a CT image. Our purpose is to make stereotactic surgery, a kind of blind surgery, as safe and reliable as a visualized procedure by intraoperative CT scanning. By the method, in which there is very little invasion under local anesthesia, evacuation of deep-seated intracerebral hematomas as well as brain abscesses and also biopsy or brachytherapy of brain tumors in the brain can be done with safety and reliability.

Stereotactic Mesencephalotomy for Pain Relief

Rostral mesencephalic reticulotomy (RMR) for pain relief was performed in 34 patients with intractable pain. Most of these patients have been followed for a long period of time postoperatively, the longest follow-up period being 11 years. Contrary to the commonly prevailed bias in the past that mesencephalotomy may be a surgical intervention with potential risk, these patients of RMR have continued to substantial improvement postoperatively in terms of their preoperative intractable painful dysesthesia after a long period of time. The results of pain relief for denervation pain as well as for nondenervation pain are surprisingly good even after unilateral procedures. There was no operative mortality. Postoperative disturbance of ocular motility has been reduced. RMR has its scientific basis in that the medial part of the reticular formation rather than the classical lateral spinothalamic tract has more significance in the central conduction of nociceptive impulses through the midbrain level, which was verified by intraoperative neuronal recording with a tungsten microelectrode. The present report emphasizes that stereotactic mesencephalotomy, if performed meticulously and precisely, is a safe surgical procedure for pain relief. Results of MRI and sensory manifestations of a patient 11 years after RMR are also presented.

A new apparatus and stereotactic method for percutaneous high cervical cordotomy

In order to elucidate pathogenesis of perifocal edema in the human brain tumors, we observed the alteration of capillary permeability between the glioblastomas with remarkable edema (4 cases) and astrocytoma with slight edema (3 cases). Specimens were studied by conventional ultrathin section and freeze-fracture replica technique. In ultrathin sections of capillaries in glioblastomas, some of these cell junctions were tortuous, elongated, in fact, open. Other capillary abnormalities included endothelial hyperplasia with extensive vesicular formation, surface infolding of endothelial cells, irregularity of the basal lamina and the presence of a large collagen filled extracellular space. In freeze-fracture replicas of capillary endothelium, pinocytotic vesicles markedly increased and were an average fo 52 per micron. Tight junction in one area was seen as network of 6 strands composed of about 100A particles, but in the other areas as one or two strands. In ultrathin sections of astrocytoma, yet there were blood vessels appeared relatively normal. In freeze-fracture replicas, pinocytotic vesicles markedly increased and were an average of 34 per micron. Tight junction was seen as network of 7 strands. We concluded that fewer strands of the tight junction play an important role in increasing the permeability in the vessels of glioblastomas with severe perifocal edema, in addition to increasing the pinocytotic vesicles.