Teruyuki Ishii

Surgical Procedure and Results of Cisternal Washing Therapy for the Prevention of Cerebral Vasospasm Following SAH

In 1994, we started cisternal washing therapy (CWT) using urokinase combined with head-shaking method in order to prevent cerebral vasospasm. In this paper, we showed the surgical procedure for CWT and reported the effect of this therapy in preventing vasospasm following SAH. A total of 332 consecutive cases with Fisher group 3 SAH since 1988 were analyzed. Of these patients, 118 cases (56 cases before 1994 and 62 cases after 1994) had not CWT, and, 214 cases after 1994 had this therapy. All of these patients had clipping surgery within 3 days following SAH, and had postoperative management both with normovolemia and normal to mild hypertension. In these two groups, the incidence of symptomatic vasospasm (transiently symptomatic vasospasm without infarction), cerebral infarction due to vasospasm on CT, and mortality and morbidity (M&M) due to vasospasm were analyzed. In the group without CWT, the incidences of symptomatic vasospasm, cerebral infarction on CT, and M&M due to vasospasm were 4.2%, 28.8%, and 17.8%, respectively. On the other hand, in the group with CWT, they were 3.7%, 6.5%, and 2.8%, respectively. In the patients with CWT, the incidence of cerebral infarction on CT due to vasospasm and M&M due to vasospasm were significantly (p < 0.05) decreased. CWT was effective in preventing cerebral vasospasm.

Preservation of the lesser occipital nerve during microvascular decompression for hemifacial spasm : Technical note

The authors report on their technique for preserving the lesser occipital nerve (LON) during lateral suboccipital craniotomy. In their technique, the LON, which runs along the surface of or just beneath the sternocleidomastoid muscle, is identified and preserved. Lesser occipital nerve preservation using their technique was attempted in 25 patients who underwent microvascular decompression for hemifacial spasm. The LON was successfully preserved in 16 of these patients, was impossible to preserve in two patients, and could not be identified in seven patients. Among the patients in whom LON preservation was successful, 87.5% were free of sensory disturbance 6 months after surgery, whereas both patients in whom the LON could not be preserved complained of sensory disturbances in the occipital area and the posterior part of the auricula. Fifty-seven percent of the patients whose LON could not be identified complained of sensory disturbance. Thus, this technique for preserving the LON reduces the incidence of sensory disturbance in the occipital region after suboccipital craniotomy for microvascular decompression for hemifacial spasm.

Symptom Predictors of Cerebrospinal Fluid Leaks

BACKGROUND Spinal cerebrospinal fluid (CSF) leaks, which are considered a cause of intracranial hypotension, generally do not cause any local symptoms. Although symptoms are key elements for further evaluation, few studies have examined symptom predictors of intracranial hypotension. The aim of this study was to determine what symptoms are predictors of CSF leaks in patients suspected of intracranial hypotension. METHODS We performed radionuclide cisternography in 207 consecutive patients suspected of intracranial hypotension. Intracranial hypotension was suspected when a patient had a history of minor trauma and complained about uncontrolled headache, cranial nerve dysfunction, autonomic dysfunction, or higher brain dysfunction. The leakage of CSF was defined as direct signs of tracer leak into the spinal epidural space or early accumulation of the tracer in the urinary bladder. We obtained information on 16 symptoms commonly reported in previous studies. RESULTS CSF leaks were observed in 154 cases (74%). Back pain, limb pain, and limb numbness were inversely associated with CSF leaks (p = 0.042, p = 0.045, and p = 0.006, respectively). In logistic regression analysis, diplopia was a positive predictor of CSF leaks (odds ratio [OR], 6.53; 95% confidence interval [CI], 1.49 to 28.51), whereas limb numbness was a negative predictor (OR, 0.38; 95% CI, 0.17 to 0.84). Of the 21 patients in whom diplopia was present and limb numbness was absent, 20 had CSF leaks (specificity, 98%; positive predictive value, 95%). CONCLUSION Some symptoms may be helpful in the diagnosis of CSF leaks in patients suspected of intracranial hypotension.

Cisternal washing therapy for the prevention of cerebral vasospasm following SAH: analysis of 308 consecutive cases with Fisher group 3 SAH

In 1994, we started cisternal washing therapy using urokinase combined with head-shaking method in order to prevent cerebral vasospasm. In this paper, we retrospectively analyzed the effect of this therapy in preventing vasospasm following SAH.

Association Between Symptom Duration and Cerebrospinal Fluid Pressure, Protein Concentration, and Number of Cells in Patients with Intracranial Hypotension

We sought to investigate the association between symptom duration and cerebrospinal fluid (CSF) pressure, protein concentration, and cell counts in patients with intracranial hypotension, in addition to examining differences between spontaneous and post-traumatic types. We investigated 115 consecutive patients with CSF leaks, demonstrated by radionuclide cisternography. In patients with spontaneous CSF leaks, a significant decrease in pressure and increase in protein concentration and number of cells were observed in patients with a symptom duration of ≤3 months compared to those with >3 months. Symptom duration was not associated with those CSF parameters in patients with post-traumatic CSF leaks.

Cisternal washing therapy in the patients with subarachnoid hemorrhage of high grades

Abstract In this paper, we retrospectively analyzed the effect of cisternal washing therapy using urokinase combined with head shaking in preventing vasospasm in patients of high subarachnoid hemorrhage (SAH) grades. Since 1988, a total of 250 consecutive cases in Fisher group 3 were retrospectively analyzed. Of these patients, 56 were diagnosed as grade 4 or 5 according to WFNS grading. Thirty cases had cisternal washing therapy and 26 cases, not. All of these patients had clipping operations within 3 days following SAH, ventricular or cisternal drainage during the clipping operation, and postoperative management with normovolemia and normo-mild hypertension. In these two groups, the incidence of symptomatic vasospasm (transiently symptomatic vasospasm without infarction), cerebral infarction on CT, and mortality and morbidity (M&M) (below moderately disabled) due to vasospasm was analyzed. In the group without cisternal washing, the incidence of symptomatic vasospasm, cerebral infarction on CT, and M&M due to vasospasm was 0%, 30.7%, and 23.1%, respectively. On the other hand, in the group with cisternal washing, the incidence of symptomatic vasospasm, cerebral infarction on CT, and M&M due to vasospasm was 13.3%, 0%, and 3.33%, respectively. Cisternal washing therapy was, therefore, effective to prevent cerebral infarction due to vasospasm.

Enhanced protein synthesis in the ipsilateral substantia nigra following middle cerebral artery occlusion in the rat

Abstract Following focal cerebral ischemia, neuronal cell death is detected in remote areas of the brain, including the ipsilateral thalamus and substantia nigra (SN), as well as in the ischemic core. We have investigated protein synthesis in the remote areas of rats exposed to focal ischemia using autoradiography. The proximal portion of the left middle cerebral artery (MCA) was permanently occluded, and at various periods (6 h, 2, 4 and 7 days and 2 and 4 weeks following ischemia) animals received a single dose of l-[2,3-3H]valine (6.7 mCi/kg). Brain sections containing the thalamus and SN were processed for autoradiography. In the ipsilateral cerebral cortex and striatum, marked impairment of protein synthesis was observed and was never completely recovered during the experiment. No changes in protein synthesis in the ipsilateral thalamus were detected during the experiment. However, a change in protein synthesis was demonstrated in the ipsilateral SN. At 2 days after MCA occlusion, incorporation of [3H]valine into the whole zona reticulata of the ipsilateral SN was slightly enhanced and the increase became evident at 4 days after ischemia. Increased incorporation of [3H]valine began to be localized in the lateral portion of the zona reticulata after 7 days and continued up to 4 weeks following ischemia. Enhanced protein synthesis during the early stage (2 and 4 days after ischemia) may be due to the activated function of the neurons in the zona reticulata and that during the late stage (7 days and 2 and 4 weeks) after ischemia to astroglial proliferation

Treatment of Cerebral Vasospasm Following Subarachnoid Hemorrhage

Cerebral vasospasm is still one of the major causes of mortality and morbidity in patients with subarachnoid hemorrhage (SAH) [ 1 ]. In spite of extensive investigation to delineate the pathogenesis of vasospasm, the optimal treatment for vasospasm has Cerebral vasospasm is still one of the major causes of mortality and morbidity in patients with subarachnoid hemorrhage (SAH) [ 1 ]. In spite of extensive investigation to delineate the pathogenesis of vasospasm, the optimal treatment for vasospasm has not yet been established. Clinical studies have demonstrated the relationship between the location and volume of the subarachnoid clots and the incidence, distribution, and the severity of vasospasm [2,3]. In 1994, we started cisternal washing therapy using urokinase, combined with head-shaking in order to prevent cerebral vasospasm in patients with SAH [4]. In this paper, we retrospectively analyzed the effect of this method in preventing vasospasm in Fisher group 3 patients with SAH.