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A 43-year-old man fell from a 1m-high truck loading platform and sustained an injury in the occiput. On admission, he was alert and neurologically intact. Computed tomography(CT)showed hemorrhage in the right sylvian fissure and parenchyma adjacent to the sphenoid wing. Magnetic resonance angiography detected no abnormalities. The course was uneventful for 11 days. However, on the 12th day, he spontaneously manifested with stupor. CT and CT angiography revealed expansion of the hemorrhage and an aneurysm arising from the origin of the M2 segment of the right middle cerebral artery. After superficial temporal artery to middle cerebral artery bypass, the aneurysm, a reddish pulsatile mass, was removed from the origin of the torn M2 segment, and the laceration was sutured. The histological diagnosis was false aneurysm. He recovered and was discharged 4 months after the trauma. Traumatic cerebral aneurysms are rare in the proximal segment of the middle cerebral artery. However, they should be distinguished from nontraumatic true aneurysms in the same region and treated as false aneurysms, which are major and critical traumatic aneurysms, for favorable outcomes.

This 64-year-old woman had undergone endoscopic carpal tunnel release(ECTR)for right carpal tunnel syndrome 16 months earlier. Thereafter, she reported persistent dysesthesia in the thumb and index finger, developed burning pain in the middle and ring finger, paleness, coldness, and edema of the hand, a decreased range in hand motion, and a painful subcutaneous nodule just distal to the portal in the forearm. Based on physical, radiological, and electrophysiological studies, the diagnosis was incomplete carpal tunnel release associated with complex regional pain syndrome(CRPS). At open revision surgery, the carpal tunnel was released completely and the nodule was removed. Symptoms other than hypesthesia in the middle and ring fingers improved. Pathologically, the nodule was an amputation neuroma. Her CRPS was attributed to ECTR complications; i.e., persistence of median nerve compression and the formation of an amputation neuroma in the palmar cutaneous branch of the ulnar nerve at the portal. Surgeons must be aware that ECTR, a less invasive technique, may result in serious complications including CRPS.

In some patients with spontaneous subarachnoid hemorrhage(SAH), initial imaging investigations may not be able to detect a bleeding source;repeat imaging may be necessary to reveal these lesions. We reviewed a consecutive series of 45 patients with SAH and negative initial digital subtraction angiograms(DSA)during a 15-year period. The aims were to document the frequency and reason for the negative initial investigations, to determine the appropriate modality and timing of repeat examinations, and to investigate the identified bleeding sources. Twenty-eight(62%)patients underwent repeat DSA, 35(78%)underwent magnetic resonance imaging(MRI), and 33(73%)underwent computed tomography angiography(CTA). Nine lesions(5 small aneurysms, 2 craniocervical junction arteriovenous fistulas, 1 arteriovenous malformation, and 1 internal carotid artery dissection)were identified on subsequent DSA after 2-3 weeks. Most aneurysms were identified on an atypical vascular tree. CTA or MRI alone were unable to disclose the culprit lesions. In retrospect, human errors including oversight were the major reasons for the negative initial investigation results. It is, however, difficult to search for a tiny vascular lesion that might be anywhere in the cranium. Repeat DSA is still the gold standard for the inspection of hidden bleeding sources in patients with SAH of unknown origin.

Doppler sonography accurately identifies occlusion of the internal carotid artery(ICA)and current surgical guidelines do not list an occluded ICA as an indication for carotid endarterectomy(CEA). We encountered an unusual case, for which we performed CEA. The left ICA was occluded by atherosclerosis, and was reconstituted via an aberrant branch of the occipital artery. A 71-year-old man was referred following brain infarction. Carotid duplex sonography(CDS)demonstrated occlusion of his left ICA, with flow in the distal ICA beyond the occlusion("Sandwich stump sign"). 3D computed tomography angiography and cervical angiography diagnosed ICA occlusion with flow in the distal ICA, and the patient underwent CEA. Careful evaluation is required when apparent occlusion of the ICA is detected to avoid overlooking a flow pattern beyond the occlusion and to determine whether repair is possible.

The outcome of severe acute subdural hematoma is unfavorable. In particular, patients with levels of consciousness of Glasgow Coma Scale(GCS)3 or 4 tend to be refractory to treatment. Decompressive craniotomy should be promptly performed to remove hematoma. However, if an operating room is not immediately available, emergency burr hole surgery is sometimes performed in the emergency room(primary care room)prior to craniotomy. A previous study has reported that the interval from injury to surgery influences the outcome of severe acute subdural hematoma. Therefore, emergency decompression is important to effectively treat patients with severe acute subdural hematoma. We present the cases of two patients with acute subdural hematomas. In both cases, emergency decompressive craniotomy(hematoma removal after craniotomy and external decompression)was performed in the emergency room of the Emergency and Critical Care Center. In both cases, the surgery was followed by favorable outcomes. Case 1 was a 36-year-old female. The patient's level of consciousness upon arrival was GCS 3. The interval from injury to diagnosis on the basis of CT findings was 75 minutes. Surgery began 20 minutes after diagnosis. Case 2 was a 25-year-old male. The second patient's level of consciousness upon arrival was GCS 4. The interval from injury to diagnosis on the basis of CT findings was 60 minutes. Surgery was begun 40 minutes after diagnosis. In both patients, we observed anisocoria and the loss of the light reflex. However, the postoperative course was favorable, and both patients were discharged. In summary, to treat severe acute subdural hematomas, early emergency decompressive craniotomy is optimal. Emergency decompressive surgery in the emergency room is independent of operating room or staff. Therefore, emergency decompressive craniotomy may improve the outcome of patients with severe acute subdural hematomas.

We describe differentiation of a spinal intramedullary lipoma from an intramedullary hematoma on magnetic resonance images (MRI) with fast spin-echo (FSE) sequences. A 60-year-old man with dysesthesia in the legs and gait disturbance, was suspected of having myelopathy at a middle thoracic lesion. MRI with FSE sequences revealed an intramedullary lesion at T7 to T8. On the basis of hyperintensity on both T1-and T2-weighted images and a perilesional hypointense rim on T2-weighted images we made a diagnosis of subacute hematoma and planned observation. However, computed tomography for associated vertebral degeneration revealed a hypodense area (-97 Hounsfield units) in the region corresponding to the lesion depicted by MRI. We revised our diagnosis to an intramedullary lipoma and debulked the lesion. The lipoma was surrounded by a thick whitish capsule. Histopathologically, the capsule contained mature fat tissue and abundant collagen. The initial diagnosis was mainly attributable to specific FSE characteristics, i. e., the depiction of fat tissue as hyperintense on both T1-and T2-weighted images. Conventional spin-echo MRI depicts fat tissue as hyperintense on T1-and as hypointense on T2-weighted images. Other factors contributing to our initial diagnosis were MRI findings suggestive of an intramedullary hematoma, i. e., the intrinsic location of the lesion and the perilesional hypointense rim on T2-weighted images ascribable to collagen present in the capsule. The accurate diagnosis of an intramedullary lipoma on FSE requires correct interpretation of the signal, which is different from the signal on conventional spin-echo MRI.

Vertebral artery dissection(VAD)presenting as isolated occipital headache and/or neck pain is being increasingly diagnosed because of the development of magnetic resonance imaging(MRI). While a majority of the patients diagnosed with this condition shows a favorable prognosis, the pain may be a predictor of fatal stroke in some patients. We aimed to find out the features of headache with VAD, identify the clinical manifestations indicative of VAD, and determine the ideal diagnostic approach to this condition to avoid fatal stroke. We reviewed medical records of 41 consecutive patients who showed VAD with isolated headache and were diagnosed between 1995 and 2008. All patients experienced pain in the occipitocervical area ipsilateral to the affected VA. Pain showed a sudden onset in 21(51%)patients, was persistent over several days in 31(76%)patients, and was severe enough to disable daily life activities in 34(83%)patients. Progression of stenosis or aneurysmal dilatation of the vessel was identified on follow-up imaging(angiography, magnetic resonance angiography)in 7 patients(17%), and was found within 14 days after pain onset in 6 of these patients(86%). Patients with persistent, severe, and unilateral pain in the occipitocervical area should undergo MRI examination, including surface anatomy scanning(SAS)imaging, and the possibility of VAD should be considered in their diagnosis. Once VAD is diagnosed, the patient should undergo meticulous blood pressure control, bed rest, and repeated MRI examination for at least 2 weeks after onset.

It may be difficult to perform CT for pediatric head trauma because of body movement and radiation exposure. Imaging application criteria were established, in which patients diagnosed as less likely to have an intracranial lesion meeting the criteria were not indicated for imaging and subjected to course observation at home, and this policy was explained to the parents. When consent was obtained, patients were followed up at home, and we checked on the condition by making a phone call 4-8 hours after injury. The patients were 103 infants aged 15 years or younger brought to the emergency medical care center of our hospital between May and August 2008. Imaging was basically indicated for cases of traffic accidents, falls from a high level, those brought in by ambulance, referred cases, and cases with disturbance of consciousness, neurologically abnormal findings, vomiting on examination, and trauma requiring X-ray examination in addition to that for the head. However, apart from these cases, imaging was not required. Imaging was not necessary for 94% of infant cases. The parents were convinced by the explanation and selected course observation at home in 94% of cases for which imaging was judged as unnecessary. None of the patients required re-examination based on the conditions reported in phone calls to homes. Imaging diagnosis for pediatric head trauma is not always necessary, and its application should be decided on after consultation. When no imaging is performed, this should be fully explained at the initial treatment before selecting course observation at home. Checking on the child's condition by making a phone call several hours after injury is useful for both patients and physicians.

When methotrexate (MTX) salvage chemotherapy is performed for primary brain malignant lymphoma, use of leucovonrin rescue must often be extended due to delays in the degradation of blood concentration. We examined whether delay in MTX blood concentration degradation could be prevented by chai-ling-tang (Sairei-to) which has diuretic action. In the five cases examined were MTX blood concentration 72 hours after MTX administration was more than 1 x 10(-7) M. A single dose of 3 g of chai-ling-tang was administered three times on the day the MTX salvage chemotherapy was subsequently performed. MTX blood concentration at 72 hours post MTX administration and subsequent chai-ling-tang administration was less than 1 x 10(-7) M in all five cases. In addition, urea nitrogen and creatinine levels in serum increased and creatinine clearance decreased following MTX administration, however these changes induced by MTX administration were reduced by chai-ling-tang administration. Chai-ling-tang was effective in preventing an MTX deferent delay in MTX high-dose therapy by improving renal blood flow.

A 73-year-old woman suffered from neck pain, progressive m tor weakness and sensory disturbance in all extremities. Neuroradiological studies revealed a retro-odontoid mass with posterior compression of the upper cervical spinal cord. Decompression of the mass was performed via a postero-lateral transdural approach, and the patient exhibited marked improvement of the symptoms. Histological examination revealed that the mass was composed of degenerative cartilaginous tissue, consistent with disc material, but the lesion was not neoplastic. Retro-odontoid disc herniation causing cervical myelopathy is very rare. We primarily discuss the surgical management of retro-odontoid disc herniation.

Enterococcal meningitis often occurs in patients with head trauma, cerebrospinal fluid leakage, or shunt devices. Herein, we describe two patients, a 12-year-old boy and a 57-year-old man, who developed meningitis due to vancomycin-resistant Enterococcus (VRE) gallinarum. Both of them had a ventriculoperitoneal shunt for hydrocephalus. The meningitis in one patient was due to fecal transmission of VRE derived from the gut and in the other from prolonged use of vancomycin. In addition, both patients were immunocompromised due to radiotherapy and steroid therapy. The mechanism of developing resistancy and the management of VRE meningitis is discussed.

The majority of anterior communicating artery(Acom) aneurysms can be approached via pterional craniotomy. When the fundus points superiorly, craniotomy in the side of A2 of posterior displacement may be advantageous for catching the aneurysm and both ACAs on the same plane. Sometimes, however, surgeons have to deliberately select a "contralateral" craniotomy to deal with other lesions in the same operative session. The first author has operated on 111 patients with Acom aneurysms during the last 8 years; 26 aneurysms projected superiorly, and 7 were approached via contralateral craniotomy because of the aneurysm multiplicity. We reviewed surgical problems in the 7 upward projecting aneurysms approached from the "contralateral" side. All aneurysms were successfully secured without any surgery related complication. However, in each case, aneurysm and both ACAs formed a straight line in the narrow surgical field, and it was difficult to handle the aneurysm behind the ipsilateral A2, particularly when it tightly adhered to the A2. Anticipating this prior to surgery allows the surgeon to know the possible problems in aneurysm dissection that may occur. Practically, wide separation of interhemispheric fissure with removal of the gyrus rectus, and dissection of the posterior aspect of the ipsilateral A2 facilitates the mobilization of A2 and exposure of the aneurysm neck. When the aneurysm is tightly adherent to the A2, however, isolation of the entire aneurysm risks tearing the aneurysm at its A2 junction. An aperture clip should be considered to avoid serious bleeding during dissection.

We encountered a rare case of symptomatic Rathke's cleft cyst associated with pituitary apoplexy. To our knowledge, six cases have been reported in the literature. The mechanism of this symptom is still obscure because of the rare pathological findings concerning Rathke's cleft cysts. Judging from the operative and the histopathologic findings, we speculate that pituitary apoplexy could occur due to hemorrhage from certain vessels such as compressed portal veins or newly organized vessels of the granulation tissue of the cyst wall.

A 19 year old male was admitted for evaluation after a seizure. Physical and neurological examination was normal. CT demonstrated an enlarged, high density mass in the right parietal lobe. MRI showed a homogeneous high intensity T1 weighted mass, surrounded by a low intensity T2 weighted rim in the right parietal lobe. Angiography did not show any abnormal findings. A diagnosis of cavernous angioma with primary bleeding in the subcortical region of the right parietal lobe was made after radiological examination. Histological examination showed a completely thrombosed aneurysm. The mechanism of the complete thrombosis and the growth of this large aneurysm and the shortcomings of radiological examination are discussed.

The occurrence and outcome of vasospasm (VS) were analyzed in 240 patients who had aneurysm surgery within 7 days of a hemorrhage during 9-year period (1981-89). Occurrence of VS was evaluated by the appearance of ischemic symptoms, (A) with or (B) without CT evidence of infarcts. The surgical outcome was assessed by the Glasgow Outcome Scale 6 months postoperatively. The results in the first and the latter halves of the period were compared. The overall incidence of VS (A+B) was 34.8% (A: 23.5%, B: 11.3%) and 33.6% (A: 15.2%, B: 18.4%) in the first and the latter halves, respectively. Thus, VS leading to infarction showed a tendency to decrease in the latter half of the period, though the overall incidence of VS itself was almost identical in both the first and second halves of the period. The results were also analyzed according to preoperative grading based on the Glasgow Coma Scale (GCS). The tendency toward decreased severity of VS in the latter term was most remarkable in patients with GCS total scores between 14 and 13. The decreased incidence of severe VS proved to be reflected in decreased mortality and in increased rate of good outcome in the latter half of the period. In order to confirm whether the results obtained in our clinic are universal, we applied the same analysis for control groups in four cooperative double-blind clinical trials performed during this period in Japan. The study again showed that the rate of infarction has decreased significantly over the decade, resulting in the improved surgical outcome.(ABSTRACT TRUNCATED AT 250 WORDS)

A series of 610 patients who had aneurysm surgery within 7 days of the hemorrhage were analyzed as to the relationship between the preoperative Glasgow Coma Scale (GCS) score and the outcome assessed by using the Glasgow Outcome Scale (GOS) at 6 months after surgery. The patient distribution in accordance with the GCS scores in descending order from 15 to 3 was as follows: 265, 109, 44, 24, 17, 20, 25, 15, 18, 12, 16, 23, and 22 cases, respectively. In general, the larger the GCS score, the better the outcome. Thus, the overall results proved to be significantly correlated with the GCS score prior to surgery (r = 0.608, P < 0.01). As for demarcation levels along the GCS axis in terms of the GOS, a significant difference in the outcome was observed at the level of GCS scores between 15 and 14 (P < 0.0001, Wilcoxon test). However, no borderlines were evident at any GCS levels other than 15/14. The problems of applying the GCS to the grading system of aneurysmal subarachnoid hemorrhage are discussed.

A 26 year-old man, who was treated for meningitis in our hospital previously, was rehospitalized 1 year later because he developed disturbance of consciousness, gait disturbance and urinary incontinence. Blood examination revealed accelerated ESR, elevated GPT, slight elevation of serum Ca, strong positive CRP, and a decrease in PHA and Con A. ACE was within normal range and tuberculin reaction was negative. Lumbar puncture revealed that the initial pressure was 310 mmH2O, cells were 152/3, and protein was 343 mg/dl. Bilateral hilar lymphadenopathy was absent in chest X ray film. Head CT revealed enlarged lateral ventricles and irregularly enhancing nodular lesions in the anterior half of the falx cerebri, and abnormally strong enhancement of the choroid plexus. Ventriculoperitoneal shunt was performed. As a diagnosis was difficult to obtain from the clinical data, biopsy of the nodular lesions was performed. The histopathologic diagnosis was sarcoidosis. Steroid hormone was administered thereafter, and the nodular lesions of the falx disappeared in the follow-up. In the literature, only 8 cases of sarcoidosis of the dura mater have been reported. Since intracranial sarcoidosis is a part of systemic sarcoidosis, its diagnosis is not difficult in most cases. However, in cases difficult to diagnose as in our case, biopsy may be necessary. When nodular lesion occurs in the dura mater, sarcoidosis must be included as a possibility in the differential diagnosis in addition to the usual meningioma, lymphoma, and metastatic brain tumor.

A 62-year-old woman was admitted complaining of clumsiness in both hands. On neurological examination, bilateral hand muscles were weak, both legs were spastic and hyperreflexic, all the extremities were hypoesthetic. Urological examination revealed detruser sphincter dyssynergia. Spinal CT scan demonstrated an iso density mass lesion in the cervical spinal cord, and it was markedly enhanced. On MRI, it was also markedly enhanced by Gd-DTPA. The operative finding was that an oval shaped tumor was buried in the spinal cord and was totally removed. Its histological diagnosis was neurofibroma. Intramedullary neurofibroma is rare and only 18 cases have been reported. In this case the tumor seemed to have arisen at the root entry zone and to have grown sub-pially.

Cerebral angiography (CAG) and transcranial Doppler (TCD) were performed at the same time in 18 patients with ruptured aneurysms within 1-3 days after onset, and the results were compared. Delayed ischemic neurological deficits (DIND) accompanying vascular spasm were detected in 8 patients, but three of the 8 patients recovered from the DIND within about 2 weeks. The CAG findings were classified into the following 3 types: (1) diffuse type showing generalized spasm of intracranial arteries (8 patients), (2) proximal type with spasm in the distal part of the internal carotid arteries and/or proximal middle cerebral arteries (5 patients) and (3) peripheral type showing spasm in the peripheral part of the middle cerebral arteries (5 patients). The TCD findings could be classified into (a) high pattern type, in which the blood flow velocity had increased (13 cases), (b) paradoxical pattern type, in which the blood flow velocity was faster in the more peripheral regions (2 cases), and (c) normal pattern type (3 cases). All 13 patients classified as diffuse type (8 patients) or proximal type (5 patients) in terms of the CAG findings showed a high pattern in TCD, indicating that TCD is also capable of diagnosing vasospasm. On the other hand, two of the 5 patients with peripheral type also showed the paradoxical pattern while the remaining 3 showed the normal pattern in TCD. DIND was detected in 6 of the 15 patients with a high or paradoxical pattern in TCD.(ABSTRACT TRUNCATED AT 250 WORDS)

A 41-year-old male was admitted to our service with right occipital pain as his chief complaint. CT and MRI examinations revealed bilateral chronic subdural hematomas. The patient had also been affected with ITP since the age of 28. Since emergency operation was thought to be dangerous, he was transferred to Tokushima University Hospital, and treated preoperatively by administration of steroids and a large dose of immunoglobulin. When his platelet count had returned to 146,000/mm3, evacuation of the hematoma through burr holes was performed successfully under local anesthesia. The postoperative course was uneventful. So far as we have been able to find in the literature, only 3 cases of ITP complicated by chronic subdural hematoma have been reported. The characteristic clinical feature of these 4 cases including our own case was noted as the absence of a history of trauma. However, the etiological relationship between ITP and chronic subdural hematoma was controversial. Occurrence of chronic subdural hematoma in patients with ITP and in patients under hemodialyzer treatment is very rare. However, intracerebral hemorrhages are rather common among such patients. So it was suggested that the tendency to bleeding among patients with ITP, and among hemodialyzer patients may contribute little as an etiological factor in the evolution of chronic subdural hematoma.

An autopsied case of primary intracranial squamous cell carcinoma (PISCC) is reported, and 25 previously reported cases of PISCC, followed by the Garcia's criteria, are reviewed. A 72-year-old female was admitted to our service with chief complaints of headache and nausea on March 30, 1988. She had no neurological deficits on admission. However, CT examination revealed a round mass lesion in the left hypothalamus with dislocation of the brain stem. The cerebrospinal fluid (CSF) examination showed squamous cell carcinoma cytologically, and slightly higher levels of beta-HCG (13.0 ng/ml) and CEA (14.2 ng/ml). Because of progressive worsening in the level of her consciousness, total removal of a suprasellar tumor was performed on April 19, 1988. Gross appearance of the tumor was yellowish, soft and encapsulated. Histologically, it was squamous cell carcinoma. She did well for several days after the operation, then deteriorated. Finally she expired because of dissemination of the carcinoma on May 14, 1988. Postmortem examination revealed a large mass of squamous cell carcinoma in her right cerebellopontine angle. Except for that in the brain, no cancer was found in her body. Immunohistological study of the tumor specimen demonstrated positive for HCG in some of the large-sized neoplastic cells. Twenty-six cases of PISCC have been reported previously, so far. However, 21 cases out of the 26 PISCC were thought to have originated from intracranial epidermoid, one from the dermoid and the other one from craniopharyngioma. In the other three cases of PISCC, including the present case, the origin of the tumor was not able to be identified.(ABSTRACT TRUNCATED AT 250 WORDS)

A 58-year-old female was admitted to our hospital because of weakness of the right lower extremity and dysesthesia of the right upper extremity. From her clinical symptoms the patient was tentatively diagnosed as having a sort of cerebral infarction and treated with administration of urokinase and antiplatelet agents. However, angiographical examination revealed a unruptured aneurysm of the A1 portion of the left anterior cerebral artery. Preoperative angiogram showed that the dome of the aneurysm compressed one of the neighboring perforating artery which arose from adjacent to the neck of the aneurysm. The patient underwent neck clipping of aneurysm successfully. During the operation, the perforator was hardly adhered to the dome of the aneurysm. So, careful dissection was made only around the neck and the perforator was spared. Her symptoms were disappeared immediately after surgery. The perforator was demonstrated with better filling in the postoperative angiogram than that in the preoperative angiogram. The pathomechanisms of cerebral ischemia caused by unruptured aneurysm were reviewed on the literature. Most of the cases were caused by release of fragmental thrombi from a large aneurysm. There was a very exceptional case whose symptoms had seemed to be related to the direct compression of the neighboring perforator by the aneurysm. The compressed perforator in this case was seemed to be corresponded with the medial proximal striate artery stated by Yaşargil.