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Masaru Nakano, Eiichi Tani, Toyokazu Fukumori, and Masayuki Yokota

✓ Experimental delayed cerebral vasospasm was produced in the canine basilar artery by intracisternal injections of blood 2 days apart. The spastic basilar artery was exposed via the transclival route under a surgical microscope, and was dilated by topical application of chlorpromazine, a calmodulin antagonist. Dilatation was dose-dependent, with a median effective dose of 37 ± 16 µM. In addition, 100 µM chlorpromazine was inserted into the cisterna magna until the intracranial pressure (ICP) reached 200 mm H2O for 30 minutes, inducing a complete reversal of angiographic delayed cerebral vasospasm in two of five animals. In other studies, the intracisternal perfusion of 100 µM chlorpromazine at 1.48 ml/min for 30 minutes with an ICP of less than 200 mm H2O induced no serious abnormalities in mean arterial blood pressure and pulse rate of normal animals. Electroencephalography during the intracisternal perfusion of chlorpromazine showed a slight to moderate increase in occurrence of theta waves. No neurological deficits or significant histological abnormalities ascribable to intracisternal chlorpromazine were found.

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Ikuya Yamaura, Eiichi Tani, Masayuki Yokota, Atsuhisa Nakano, Masahiro Fukami, Keizo Kaba, and Tsuyoshi Matsumoto

Object. Surgical or endovascular occlusion of the parent artery proximal to an aneurysm has been recommended for treatment of dissecting aneurysms of the intracranial posterior circulation. However, dissecting aneurysms may rupture even after proximal occlusion because distal progression of thrombus is necessary to occlude the dissecting aneurysm completely, and this may be delayed by the presence of retrograde flow. In this article the authors present their experience in treating six patients with ruptured dissecting aneurysms.

Methods. The authors report on six patients with a ruptured dissecting aneurysm in the posterior fossa who were successfully treated by endovascular occlusion of the aneurysm by using Guglielmi detachable coils. The procedure was particularly aimed at occluding the dissected site.

Conclusions. At the present time, endovascular occlusion of the dissected site is a safe, minimally invasive, and reliable treatment for dissecting aneurysms when a test occlusion is tolerated and adequate collateral circulation is present.

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Masato Matsumoto, Masanori Sato, Masayuki Nakano, Yuji Endo, Youichi Watanabe, Tatsuya Sasaki, Kyouichi Suzuki, and Namio Kodama

Object. The aim of this study was to assess whether aneurysm surgery can be performed in patients with ruptured cerebral aneurysms by using three-dimensional computerized tomography (3D-CT) angiography alone, without conventional catheter angiography.

Methods. In a previous study, 60 patients with subarachnoid hemorrhage (SAH) from ruptured aneurysms were prospectively evaluated using both 3D-CT and conventional angiography, which resulted in a 100% accuracy for 3D-CT angiography in the diagnosis of ruptured aneurysms, and a 96% accuracy in the identification of associated unruptured aneurysms. The results led the authors to consider replacing conventional angiography with 3D-CT angiography for use in diagnosing ruptured aneurysms, and to perform surgery aided by 3D-CT angiography alone without conventional angiography. Based on the results, 100 consecutive patients with SAH who had undergone surgery in the acute stage based on 3D-CT angiography findings have been studied since December 1996. One hundred ruptured aneurysms, including 41 associated unruptured lesions, were detected using 3D-CT angiography. In seven of 100 ruptured aneurysms, which included four dissecting vertebral artery aneurysms, two basilar artery (BA) tip aneurysms, and one BA—superior cerebellar artery aneurysm, 3D-CT angiography was followed by conventional angiography to acquire diagnostic confirmation or information about the vein of Labbé, which was needed to guide the surgical approach for BA tip aneurysms. All of the ruptured aneurysms were confirmed at surgery and treated successfully. Ninety-three patients who underwent operation with the aid of 3D-CT angiography only had no complications related to the lack of information gathered by conventional angiography. The 3D-CT angiography studies provided the authors with the aneurysm location as well as surgically important information on the configuration of its sac and neck, the presence of calcification in the aneurysm wall, and its relationship to the adjacent vessels and bone structures.

Conclusions The authors believe that 3D-CT angiography can replace conventional angiography in the diagnosis of ruptured aneurysms and that surgery can be performed in almost all acutely ruptured aneurysms by using only 3D-CT angiography without conventional angiography.

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Eiichi Tani, Yukio Maeda, Toyokazu Fukumori, Masaru Nakano, Nobuo Kochi, Tatsuo Morimura, Masayuki Yokota, and Tsuyoshi Matsumoto

✓ The authors report the results of inhibition of thromboxane A 2 synthetase in 49 consecutive patients with subarachnoid hemorrhage (SAH). These unselected Grade I to IV patients all had a ruptured aneurysm of the anterior circle of Willis, and were operated on within 72 hours after SAH. Twenty-seven patients were treated postoperatively by an intravenous infusion of sodium(E)-3-[4-(3-pyridylmethyl)-phenyl]-2-propenoate (OKY-1581), a selective inhibitor of thromboxane A2 synthetase, at 5 µg/kg/min for 10 to 14 days, and the remaining 22 patients did not receive this drug. Both groups of patients had similar age distribution and preoperative neurological conditions. A suggestive but statistically insignificant improvement was found in postoperative angiographic vasospasm, ischemic symptoms, and overall outcome in the group receiving OKY-1581. The incidence of low-density areas on the postoperative computerized tomography scans was significantly decreased in patients treated with OKY-1581 infusion.

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Hiroki Hori, Hirokazu Iwamuro, Masayuki Nakano, Takahiro Ouchi, Takashi Kawahara, Takaomi Taira, Keiichi Abe, Ken Iijima, and Toshio Yamaguchi

OBJECTIVE

In transcranial magnetic resonance imaging–guided focused ultrasound (TcMRgFUS), a high skull density ratio (SDR) is advantageous to achieve a sufficiently high temperature at the target. However, it is not easy to estimate the temperature rise because the SDR shows different values depending on the reconstruction filter used. The resolution characteristic of a computed tomography (CT) image depends on a modulation transfer function (MTF) defined by the reconstruction filter. Differences in MTF induce unstable SDRs. The purpose of this study was both to standardize SDR by developing a method to correct the MTF and to enable effective patient screening prior to TcMRgFUS treatment and more accurate predictions of focal temperature.

METHODS

CT images of a skull phantom and five subjects were obtained using eight different reconstruction filters. A frequency filter (FF) was calculated using the MTF of each reconstruction filter, and the validity of SDR standardization was evaluated by comparing the variation in SDR before and after FF correction. Subsequently, FF processing was similarly performed using the CT images of 18 patients who had undergone TcMRgFUS, and statistical analyses were performed comparing the relationship between the SDRs before and after correction and the maximum temperature in the target during TcMRgFUS treatment.

RESULTS

The FF was calculated for each reconstruction filter based on one manufacturer's BONE filter. In the CT images of the skull phantom, the SDR before FF correction with five of the other seven reconstruction filters was significantly smaller than that with the BONE filter (p < 0.01). After FF correction, however, a significant difference was recognized under only one condition. In the CT images of the five subjects, variation of the SDR due to imaging conditions was significantly improved after the FF correction. In 18 cases treated with TcMRgFUS, there was no correlation between SDR before FF correction and maximum temperature (rs = 0.31, p > 0.05); however, a strong positive correlation was observed after FF correction (rs = 0.71, p < 0.01).

CONCLUSIONS

After FF correction, the difference in SDR due to the reconstruction filter used is smaller, and the correlation with temperature is stronger. Therefore, the SDR can be standardized by applying the FF, and the maximum temperature during treatment may be predicted more accurately.

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Shuhei Morita, Masayuki Nitta, Yoshihiro Muragaki, Takashi Komori, Kenta Masui, Takashi Maruyama, Koichi Ichimura, Yoshiko Nakano, Tatsuo Sawada, Shunichi Koriyama, Shunsuke Tsuzuki, Takayuki Yasuda, Kazutoshi Hashimoto, Akihiro Niwa, and Takakazu Kawamata

In this report, the authors present the first case of adult brainstem pilocytic astrocytoma (PA) with the H3 K27M mutation. A 53-year-old man was incidentally found to have a 2.5-cm partially enhanced tumor in the tectum on MRI. The enhancement in the lesion increased over 3 years, and gross-total removal was performed via the occipital transtentorial approach. The resected tissue indicated PA, WHO Grade I, and genetic analysis revealed the H3 K27M mutation. However, although the radiological, surgical, and pathological findings all corresponded to PA, this entity can easily be misdiagnosed as diffuse midline glioma with the H3 K27M mutation, which is classified as a WHO Grade IV tumor according to the updated classification. This case highlights the phenotypic spectrum of PA, as well as the biology of the H3 K27M–mutated gliomas, and may prove to be an exception to the rule that diffuse midline gliomas with the H3 K27M mutation behave in an aggressive manner. Based on the findings of this case, the authors conclude that, in addition to detecting the existence of the H3 K27M mutation, an integrated approach in which a combination of clinical, pathological, and genetic information is used should be applied for accurate diagnosis and determination of the appropriate treatment for diffuse midline gliomas.