INTRAOPERATIVE ANGIOGRAPHIC ASSESSMENT OF RECONSTRUCTED ARTERY AND USEFULNESS OF SAPHENOUS VEIN GRAFT BRIDGING IN EARLY THROMBOSIS OCCLUSION AFTER CAROTID ENDARTERECTOMY

Early postoperative thrombosis-occlusion of the internal carotid artery after carotid endarterectomy plays a major role in postoperative neurologic morbidity and mortality. To prevent this terrible complication, many surgeons are trying various prophylactic methods such as saphenous vein patch angioplasty, prolonged use of heparin, intraoperative Doppler ultrasound assessment, and so on. However, complete protection from postoperative thrombosis-occlusion is difficult. We have performed 47 carotid endarterectomies on 43 patients in the last three years. In 28 of these endarterectomies, primary closure for arteriotomy was performed, and in 19 cases, endarterectomies were reconstructed with saphenous vein patch angioplasty. An intraoperative angiographical assessment of the reconstructed segment was done in all endarterectomies after the reversing of heparin given during the carotid arterial surgical maneuver, and restenosis, or thrombosis-occlusion, was also checked. In three arteries, restenosis was demonstrated and repair was performed with vein graft angioplasty. Three of 28 arteries recontructed with primary closure and 1 of 19 arteries with vein patch angioplasty showed thrombosis-occlusion. Although vein patch angioplasty was done immediately for the primarily closured arteries, occlusion occurred again in two arteries. One artery with patch angioplasty also reoccluded. For these arteries, saphenous vein graft bridging between common carotid artery with an intact intima and internal carotid artery with an intact intima was performed. Postoperative angiogram showed good blood flow through the vein graft bridge. These results suggest that intraoperative angiography gives important imformation about the reconstructed arterial segment and that saphenous vein bridging is very useful in arteries with thrombosis-occlusion following carotid endarterectomy

A CASE OF DIABETES INSIPIDUS ACCOMPANYING THIRST DISORDER ASSOCIATED WITH HYPEROSMOLAR DIABETIC COMA

The case of a 14-year-old female who suffered from hyperosmolar diabetic coma (HODC) after resection of craniopharyngioma and during treatment for hypopituitarism and diabetes insipidus is presented. In Aug. 1989, craniopharyngioma was diagnosed and she underwent resection surgery and radiotherapy. Since then, she had been on supplemental therapy with hydrocortisone and thyroxin and desmopressin (DDAVP). On Jan. 17, 1992, she fell into HODC upon ingesting a large amount of soft drink to supplement water due to persistent polyuria. She improved quickly when supplementary fluids and insulin were administered. She had demonstrated no abnormality in glucose tolerance prior to this manifestation. Insulin therapy was deemed unnecessary after her recovery from HODC. Because of a disorder in the central nervous thirst mechaninm, she lacked the sense of thirst and concomitantly the thirst-mediated water intake in spite of elevated plasma osmolarity due to dehydration and hyperglycemia. This seemed to be the cause of her accelerating dehydration. The resulting insulin resistance then brought about her HODC. Thus, it is difficult to consider such a case of HODC as symptomatic of diabetes when no abnormality in glucose tolerance either before manifestation or after restoration can be found. It should rather be considered as a case of “dehydration hyperglycemia" and be treated as such

CLINICOPATHOLOGICAL STUDY OF CEREBRAL SUBCORTICAL CAVERNOUS ANGIOMA AS EPILEPTOGENIC FOCUS

The authors conducted a comparative histological study of two groups of patients with cerebral subcortical cavernous angioma. One group was composed of 5 asymptomatic cases detected accidentally. The other group was composed of 4 patients presenting as epilepsy. The results obtained may be summarized as follows ; 1) Hemosiderin deposit and gliosis were seen in all cases examined ; 2) Granulomatous change was a histological finding associated with epileptogenesis ; 3) The histological changes, starting with proliferation of collagen fibers and leading to hyaline degeneration, calcification, and then hemangioma calcificans, seem to represent a course of spontaneous healing, when viewed from epileptogenesis

A NEW METHOD OF SURGICAL TREATMENT OF LUMBAR SPINAL STENOSIS

As the treatment of lumbar or lumbosacral stenosis, laminectomy with the preservation of tissues supporting the spine and the embracement of the exposed dura mater with thin silicone rubber to prevent the occurrence of restenosis due to exuberant fibrous tissue formation at the operative site have been performed over a period of seven years. Before the prevention of restenosis with silicone rubber, we had to reoperate in cases which developed recurrent symptoms resulting from restenosis of the lumbosacral canal. This operation that we describe is technically feasible and with practical benefit can be done routinely for spinal decompression not only in the lumbosaral, but also in cervical spinal region without requiring an extensive laminectomy

DYSPHAGIA CAUSED BY ANTERIOR CERVICAL OSTEOPHYTES

Although cervical spondylosis is a common disorder, dysphagia induced by osteophyte formation is uncommon. Reports in the literature show that vertebral hypertrophic spurs causing dysphagia result from bony degeneration or idiopathic causes (diffuse idiopathic skeletal hyperosteosis: DISH) (Forestier's disease). We present a case suffering dysphagia secondary to cervical osteophytes. A 62-year-old male patient presented with a complaint of dysphagia. Physical examination showed no abnormality. A cervical X-ray and computed tomography (CT) showed a large bone spur originating from the anterior surface of the C3/4. Barium esophagography revealed osteophytic spurs in the anterior aspect of C3/4 vertebrae, in close approximation to the inlet of the esophagus, obstructing the esophagus passage by external compression. Anti-inflammatory therapy administered did not provide relief of the patient's complaint. Functional improvement was immediate after surgical removal of the osteophyte using ultrasonic bone curettage via an anterior cervical approach. Surgery is mandatory if medical care fails and dysphagia is complete