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A 30-year-old woman presented with traumatic carotid-cavernous fistula associated with persistent primitive trigeminal artery (PPTA) manifesting as right conjunctival chemosis, exophthalmos, and diplopia. The lesion was treated successfully by trans-arterial coil embolization using the double catheter method with balloon assist. Injury to the PPTA is relatively rare and the PPTA should be sacrificed together with the fistula during the repair.

Classification of hydrocephalus is the most crucial but the most complicated academic challenge within the hydrocephalus research field. The major difficulty in this challenge arises from the fact that the classification is based on almost all subjects in hydrocephalus research, i.e., definition and terminology of hydrocephalus, pathophysiology, hydrocephalus chronology, specific forms of hydrocephalus, associated congenital anomalies/syndrome and underlying conditions, diagnostic procedures for hydrocephalus, and treatment modalities in hydrocephalus. The current status of the classification of hydrocephalus in individual subgroups was reviewed and summarized from publications in the last 60 years (1950-2010), and discussed focusing on the variety of characteristics in hydrocephalus, with more and more new aspects recently disclosed not only in fetal and pediatric but also in adult hydrocephalus. A recently-reported classification of hydrocephalus, "Multi-categorical Hydrocephalus Classification" provides comprehensive coverage of the entire aspects of hydrocephalus with current important classification categories and subtypes.

A 68-year-old woman presented with a rare huge right occipital cystic lesion manifesting as progressive left hemiplegia. Cranial computed tomography revealed a 4 x 7 cm right occipital lobe thin-walled cyst with midline shift and compression of the ipsilateral ventricle. The patient underwent a single burr hole operation for cystography and delineation of the cyst anatomy, then a separate right parieto-occipital craniotomy with complete cyst evacuation, corticotomy, and ventriculostomy. The presumptive diagnosis was arachnoid cyst. The symptoms had completely resolved by 4 months after surgery with nearly normal neuroimaging appearance after 7 months. Cystography followed by craniotomy and ventriculostomy may be effective for supratentorial arachnoid cysts.

Four patients presented with isolated dilation of the trigono-inferior horn associated with either mass lesion at the trigone of the lateral ventricle or with shunt over-drainage. We investigated clinical symptoms, course, and neuroradiological findings of these cases. The pressure of the isolated ventricle was measured or estimated at surgery in all cases. The common symptoms were recent memory disturbance and contralateral homonymous hemianopia. Contralateral hemiparesis was observed occasionally. Rapid deterioration of the isolation caused uncal herniation in one case. Comma-shaped dilation of the inferior horn was observed in all cases. Midline shift was not conspicuous except in one case. Intraventricular pressure at surgery was 18 cmH2O, 35 cmH2O, 3 cmH2O, and within normal range. These cases had very similar clinical symptoms and neuroradiological findings. The pathophysiology of isolation suggested three types of isolation (high-, normal-, and low-pressure isolation), depending on the pressure of the isolated ventricle. The isolation of trigono-inferior horn is an important clinical entity as it may cause uncal herniation in patients with high-pressure lesions.

Twelve patients with growth hormone-producing pituitary adenomas were investigated to evaluate correlations between magnetic resonance (MR) appearance and tissue characteristics, sellar expansion, suprasellar tumor extension, and tumor consistency. MR imaging could detect microadenomas with a characteristic enhancement delay of gadolinium-diethylenetriaminepenta-acetic acid in the surrounding normal pituitary gland. Macroadenomas and giant tumors appeared on T2-weighted images as mostly high intensity, while varied greatly on T1-weighted images. The signal intensities of growth hormone-producing adenomas were more homogeneous (80%) than those of other functioning and non-functioning adenomas on T1-weighted images. However, there was no typical MR imaging for the tissue characteristics of the growth hormone-producing adenomas, and no particular correlation with suprasellar extension or consistency. Postoperative MR findings showed that the transcranial approach was superior for total or subtotal removal of large tumors, especially with suprasellar extension up to the upper third ventricle. The transsphenoidal approach can achieve a satisfactory decompressive effect on the optic chiasm, but more radical removal is required to achieve a normal hormone level.

Fetal hydrocephalus was induced by single intraperitoneal injection of 8 mg/kg 6-aminonicotinamide (6-AN), a niacinamide antagonist, in Sprague-Dawley rat on day 13 of gestation. Materials for histological examination were obtained by uterotomy 1, 2, 4, and 8 days after injection, and untreated fetuses of the same ages were used as controls. Macrocephalus was clear at day 17 (4 days after injection), when cerebral dysgenesis was suggested by bromodeoxyuridine immunohistochemical study. The entire ventricular system was dilated, including the aqueduct and foramen of Monro, and hypoplasia of the cerebellum was also observed. On day 21, macrocephalus was remarkable, and considerable hypoplasia of the choroid plexus and cerebellum and agenesis of the corpus callosum were recognized. These results indicate that this experimental hydrocephalic model associated with various central nervous system anomalies mimics human Dandy-Walker syndrome, suggesting the pathogenesis of Dandy-Walker syndrome to be a feature of systemic metabolic deficits.

Cosmetic cranio-orbital reconstructive surgery was carried out on a 22-year-old male, the longest surviving case of cloverleaf skull syndrome reported. He previously underwent classical linear suturectomy for synostotic sutures and temporal cranioplasty. Fortunately, hydrocephalus became arrested so did not require continuous cerebrospinal fluid drainage through shunt tube. His intelligence quotient was in the 40s. The present problem was mainly of cosmetic cranio-orbital corrections of shallow orbits with resultant exophthalmos, frontal dysgenesis, and marked temporal bossings. Bilateral orbital advance, lateral canthal/pterional reshaping, frontal remodeling, and temporal reduction cranioplasty were performed. The postoperative outcome was satisfactory. The cloverleaf skull deformity is etiologically and pathologically heterogeneous, so radical surgical reconstructive procedures should be planned and designed individually.

Twenty hydrocephalic patients diagnosed in the third trimester of fetal life were evaluated and followed during a 7-year period. The factors affecting the prognosis, including the type of hydrocephalus, underlying conditions, associated anomalies, time of diagnosis and delivery, fetal period after diagnosis, head circumference and degree of ventriculomegaly at birth, and age at treatment, were comprehensively analyzed. The difference between final outcomes as assessed by developmental quotient (DQ) or intelligence quotient (IQ) were statistically tested with computation by means of STAX packages in an NEC 9801 VX. Hydrocephalus as an isolated defect occurred in six cases (30%), was associated with other central nervous system anomalies in nine (45%), and was secondary to intrauterine intraventricular hemorrhage or brain tumor in five (25%). The average age at the time of diagnosis was 33.9 weeks of gestation (range, 27-40 weeks). One fetus was treated by transabdominal cephalocentesis, but the majority of patients underwent ventriculoperitoneal shunt postnatally. The final IQ or DQ scores ranged from 20 to 120 (mean score, 50.6). The data analyses revealed that the only significant factor affecting outcome was the fetal period after diagnosis of hydrocephalus (r = -0.5076, p less than 0.01). Our data supports the fact that the results of an on-going hydrocephalic state may become irreversible during fetal life. It is emphasized that establishment of a more precise pathophysiological evaluation, and a less invasive but more reliable decompressive technique for fetal hydrocephalus, is urgent.

The nature and sequence of the radiation-induced changes in the brain were studied postmortem in 34 children with glioma, 22 of whom underwent central nervous system radiation therapy. Twenty received whole-brain or whole-neuroaxis radiation at a total mean dosage of 4063 cGy. Brain tissue alterations were analyzed histologically by means of various staining methods, including immunohistochemical techniques. The histological features of irradiated brains were compared with those of non-irradiated brains. Microscopic findings included demyelination (seven cases), focal necrosis (six cases), cortical atrophy (four cases), endothelial proliferation (four cases), and telangiectatic vascular proliferation with vascular thickening and oozing of a thick fluid (one case). Such findings were rare in non-irradiated patients. Demyelination was observed earliest in a patient who died 5 months after radiation therapy and was more common after 9 months. Focal necrosis was first observed 9 months post-irradiation but was more advanced and extensive after 1 year. Calcified foci were found only after 60 months. Various vascular changes such as vascular thickening and thrombosis suggested ischemic insult to the brain as a late effect of radiation injury. The results of this study suggest that the immature brain may be more sensitive to radiation than is the adult brain, and that the manifestations of radiation-induced injury depend on the time elapsed after irradiation.

A 26-year-old male was injured in a motorcycle accident and arrived unconscious at a local general hospital. Lack of improvement despite intensive care prompted his referral to the neurosurgical department, approximately 10 hours after the accident. On neurological examination his Glasgow Coma Scale score was 8, and mild right hemiparesis and right radial nerve palsy were noted. There was no skull fracture. Computed tomography disclosed intraventricular hemorrhage and small hemorrhagic foci in the prepontine area and the border between the gray and white matter. No hemorrhage was demonstrated in the corpus callosum. Magnetic resonance imaging (MRI) was performed 3 weeks after admission with a 0.5-tesla resistive Vista magnetic resonance scanner. The inversion recovery technique was used, with a repetition time (TR) of 2100 msec, an inversion time of 500 msec, and an echo time (TE) of 40 msec, for T1-weighted images. The spin-echo technique was used, with a TR of 2000 msec and a TE of 80 msec, for T2-weighted images. In the body and splenium of the corpus callosum, T1-weighted images showed a spotty area of low signal intensity with an irregular margin; this area was of high signal intensity on T2-weighted images. On repeat MRI performed 4 months after injury, T1-weighted images showed, in the same region, granular low signal intensity, while T2-weighted images showed high signal intensity. The MRI findings in the subacute and chronic stages of diffuse axonal injury are discussed.

The prognosis of fetal hydrocephalus is poor and the results of intrauterine decompression have so far been unsatisfactory. Although several factors have been known to affect the prognosis of intrauterine hydrocephalus, few histological studies of preterm hydrocephalus and no immunohistochemical analyses have been reported to date. In eight fetal cases of untreated preterm hydrocephalus, the authors morphologically studied neuronal maturation by means of immunohistochemical and specific myelin staining techniques. The patients' gestational ages at death ranged from 20 to 40 weeks (mean, 30 weeks). There were two cases of simple form of hydrocephalus, two of cerebral dysgenesis (hydranencephaly and holoprosencephaly), and four of hydrocephalus secondary to intraventricular hemorrhage. Relatively primitive neuronal developmental processes, such as neuronal cell proliferation and migration, were found to be altered by rapidly progressive simple form of intrauterine hydrocephalus, whereas the neuronal maturation disorder was obviously the primary condition in dysgenetic hydrocephalus. Hydrocephalus itself, however, caused additional damage in the presence of delayed but slowly progressing neuronal development. Secondary hydrocephalus initially reflects impairment of previously normal neuronal maturation. In this situation, too, hydrocephalus per se further compromised the potential for continued neuronal development. The results of this study imply that the pathoembryological concepts of fetal hydrocephalus are not so simple. Early decompression may preserve the potential for further neuronal maturation in fetal hydrocephalus.