✓ A method is described which has been found capable of detecting subarachnoid hemorrhage (SAH) up to 15 to 17 weeks after its occurrence. The episode of SAH was confirmed by bloody and/or xanthochromic cerebrospinal fluid (CSF) at the time of SAH onset. In this study, 47 samples of lumbar CSF from diagnostically confirmed SAH patients were used. The CSF cells were collected onto slides and stained with May-Gruenwald-Giemsa or Perl's reagent. Iron-positive cells were detected at 1 week, increased by 4 to 6 weeks to 8.5% of total nucleated cells, and decreased to 1% by 15 to 17 weeks. All 27 samples obtained at 2 to 9 weeks after SAH showed iron-positive cells. No iron-positive cells (false-negative samples) were noted in 25% (one of four) of samples obtained during the first week, and in 33% (one of three) of samples obtained 10 to 12 weeks and 15 to 17 weeks after SAH. Of the total samples (37) obtained within 17 weeks after SAH, 8.1% (three of 37) were false negative. No iron-positive cells were detected in samples obtained later than 21 weeks after the SAH episode (10 samples).
Umeo Ito and Yutaka Inaba
Study in normal rabbit brain
Toshihiko Kuroiwa, Matsutaira Tsuyumu, Hidenori Takei, and Yutaka Inaba
✓ The effect of Nd:YAG and CO2 laser beams on cerebral microvasculature was examined in experimental animals. Soft x-ray microangiography and histological examination of the brain after Nd:YAG laser exposure revealed broad avascular or oligovascular zones in the irradiated and the surrounding edematous tissue, in which the surviving vessels were narrowed and tapered without significant leakage of blood. After CO2 laser exposure, a wedge-shaped tissue defect surrounded by layers of charring, coagulation, and edema was observed. The main finding in the surrounding coagulation and edematous layers was dilatation of the vessels. Hemorrhage was sometimes observed, mainly in the edematous layer. These findings seem to explain the effective hemostatic capability of the Nd:YAG laser and the occasional hemorrhage following CO2 laser exposure, especially at high energy output.
Toshihiko Kuroiwa, Mitsuru Seida, Shuuichi Tomida, Hideo Hiratsuka, Riki Okeda, and Yutaka Inaba
✓ The development of ischemic edema and blood-brain barrier (BBB) disruption during the 1st day of experimental cerebral infarction induced by transorbital occlusion of the middle cerebral artery (MCA) in cats was evaluated by computerized tomography (CT) scanning and compared to gravimetric and pathological studies. Regional cerebral blood flow was measured using the hydrogen clearance technique or stable xenonenhanced CT scanning. Edema was observed gravimetrically and microscopically as early as 1 hour after the onset of ischemia in the cortex and at 3 hours or later in both the cortex and white matter. However, a significant decrease of Hounsfield numbers on the CT scans was not detectable at 1 or 3 hours and was scarcely visible at 9 hours after occlusion. Disruption of the BBB was detected by leakage of Evans blue dye at 3 hours after the occlusion in two of six animals and at 9 hours in five of five animals. However, CT scanning after infusion of contrast material showed no significant increase in Hounsfield number even 24 hours after MCA occlusion. These discrepancies should be emphasized when the dynamics of ischemic edema and BBB disruption are evaluated for clinical therapy by CT scanning.
Hideo Hiratsuka, Hitoshi Tabata, Shin Tsuruoka, Masaru Aoyagi, Kodai Okada, and Yutaka Inaba
✓ Hydrocephalus was induced in 13 dogs by injecting kaolin into the cisterna magna and was evaluated by computerized tomography (CT) scans. Modification of periventricular hypodensity was observed by metrizamide-enhanced CT ventriculography. Periventricular hypodensity was seen as early as 12 hours after kaolin injection. On CT ventriculography, metrizamide stayed longer in the ventricles of hydrocephalic dogs than in those of normal dogs, and migrated into the areas of periventricular hypodensity; the changes became significant within 12 to 24 hours. Four of the dogs were killed immediately after CT ventriculography, and the iodine concentration was measured. Iodine concentration was highest in the periventricular white matter, followed by the basal ganglia, and it was low in the cerebral and cerebellar cortex. When the change in Hounsfield units found by CT ventriculography at the regions of interest was compared to the actual iodine concentrations, the figures were quite compatible. Similarly, the specific gravity was measured in tissue from various parts of the brain of two hydrocephalic dogs, and compared against the value of that from five normal dogs. The specific gravity values were particularly low in the periventricular white matter of the hydrocephalic brains, suggesting a higher water content in that region. Since the increased migration of metrizamide occurred at the same region, it is suggested that development of periventricular hypodensity is due to increased transit of cerebrospinal fluid from the ventricles to the white matter.
Motonori Kohno, Yuichi Iwamura, Riki Inasaka, Gosuke Akiyama, Shota Higashihira, Takuya Kawai, Takanori Niimura, and Yutaka Inaba
This retrospective study aimed to clarify the influence of comorbid severe knee osteoarthritis (KOA) on surgical outcome in terms of sagittal spinopelvic/lower-extremity alignment in elderly patients with degenerative lumbar spondylolisthesis (DLS).
In total, 110 patients aged at least 65 years (27 men, 83 women; mean age 74.0 years) who underwent short-segment lumbar fusion were included in the present study. Using the Kellgren-Lawrence (KL) grading system, patients were categorized into those with no to mild KOA (the mild-OA group: KL grades 0–2), moderate KOA (moderate-OA group: KL grade 3), or severe KOA (severe-OA group: KL grade 4). Surgical results were assessed using the Japanese Orthopaedic Association (JOA) scoring system, and spinopelvic/lower-extremity parameters were compared among the 3 groups. Adjacent-segment disease (ASD) was assessed over a mean follow-up period of 4.7 years (range 2–8.1 years).
The study cohort was split into the mild-OA group (42 patients), the moderate-OA group (28 patients), and the severe-OA group (40 patients). The severe-OA group contained significantly more women (p = 0.037) and patients with double-level listhesis (p = 0.012) compared with the other groups. No significant differences were found in mean postoperative JOA scores or recovery rate among the 3 groups. The mean postoperative JOA subscore for restriction of activities of daily living was only significantly lower in the severe-OA group compared with the other groups (p = 0.010). The severe-OA group exhibited significantly greater pelvic incidence, pelvic tilt, and knee flexion angle (KFA), along with a smaller degree of lumbar lordosis than the mild-OA group both pre- and postoperatively (all p < 0.05). Overall, the rate of radiographic ASD was observed to be higher in the severe-OA group than in the mild-OA group (p = 0.015). Patients with ASD in the severe-OA group exhibited significantly greater pelvic tilt, pre- and postoperatively, along with less lumbar lordosis, than the patients without ASD postoperatively (all p < 0.05).
A lack of lumbar lordosis caused by double-level listhesis and knee flexion contracture compensated for by far greater pelvic retroversion is experienced by elderly patients with DLS and severe KOA. Therefore, corrective lumbar surgery and knee arthroplasty may be considered to improve sagittal alignment, which may contribute to the prevention of ASD, resulting in favorable long-term surgical outcomes.
Jun Muto, Yutaka Mine, Yu Nakagawa, Masahiro Joko, Hiroshi Kagami, Makoto Inaba, Mitsuhiro Hasegawa, John Y. K. Lee, and Yuichi Hirose
As chemotherapy and radiotherapy have developed, the role of a neurosurgeon in the treatment of metastatic brain tumors is gradually changing. Real-time intraoperative visualization of brain tumors by near-infrared spectroscopy (NIRS) is feasible. The authors aimed to perform real-time intraoperative visualization of the metastatic tumor in brain surgery using second-window indocyanine green (SWIG) with microscope and exoscope systems.
Ten patients with intraparenchymal brain metastatic tumors were administered 5 mg/kg indocyanine green (ICG) 1 day before the surgery. In some patients, a microscope was used to help identify the metastases, whereas in the others, an exoscope was used.
NIRS with the exoscope and microscope revealed the tumor location from the brain surface and the tumor itself in all 10 patients. The NIR signal could be detected though the normal brain parenchyma up to 20 mm. While the mean signal-to-background ratio (SBR) from the brain surface was 1.82 ± 1.30, it was 3.35 ± 1.76 from the tumor. The SBR of the tumor (p = 0.030) and the ratio of Gd-enhanced T1 tumor signal to normal brain (T1BR) (p = 0.0040) were significantly correlated with the tumor diameter. The SBR of the tumor was also correlated with the T1BR (p = 0.0020). The tumor was completely removed in 9 of the 10 patients, as confirmed by postoperative Gd-enhanced MRI. This was concomitant with the absence of NIR fluorescence at the end of surgery.
SWIG reveals the metastatic tumor location from the brain surface with both the microscope and exoscope systems. The Gd-enhanced T1 tumor signal may predict the NIR signal of the metastatic tumor, thus facilitating tumor resection.