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The need for resection of the meningioma capsule has long been debated and remains controversial. Even the definition of a capsule does not seem to have been established. We described the histopathological findings of the so-called capsule and the necessity for resection, considering tumor cell invasion and recurrence, based on a literature review.

Gross total tumor resection for sinonasal malignancy with orbital apex extension requires orbital exenteration and bony skull base resection around the orbital apex with sufficient margins. With a detailed discussion of the anatomy, we describe our surgical procedure for extended orbital exenteration with orbital apex resection for sinonasal malignancy.

Intracranial arachnoid cysts(ACs)are thought to develop during infancy and remain clinically asymptomatic in most cases. AC is often diagnosed incidentally during imaging studies. The prognosis for the recovery of newly developed symptoms is usually favorable. However, the prognosis following surgery for chronic symptoms is still unclear. Herein, we report the case of an adult patient with right convexity AC whose chronic symptoms improved after surgery. The patient was a 63-year-old woman who had an AC in her right temporal convexity since the age of 59, without any symptoms, which was incidentally diagnosed on MRI. At 61 years of age, she visited a hospital complaining of slight weakness in her left upper limb. No changes were found on the MRI scan, but her visual field indicated the presence of a left homonymous hemianopia, and her cognitive function had decreased slightly. Two years later, she developed modest left hemiparesis;therefore, she underwent cystoventriculostomy to improve the symptoms of hemiparesis. After the surgery, the left hemiparesis recovered fully, and a remarkable improvement was noted in the left homonymous hemianopia and the degenerated cognitive functions. There are no clear guidelines regarding the surgical indications for AC in adults. Many reports suggest that new symptoms related to AC can be improved with surgery. However, amelioration of chronic symptoms has rarely been reported. The present case indicates that it is possible to improve the chronic symptoms of AC in adults with surgical procedures.

Chordomas are uncommon tumors occurring from remnants of the notochord. They are mainly localized in the sacrococcygium, the spine and the central skull base. Here we report a rare case of clivus chordoma presenting with cerebrospinal fluid(CSF)rhinorrhea. A 41-year-old man with a 11-year history of recurrent CSF rhinorrhea was found to have a clival lesion. Bone image CT revealed lytic bone destruction at the clivus. MRI showed a cystic mass with a membrane enhanced by gadolinium protruding into the sphenoid sinus thorough the bone defect. However, there was no solid component observed. The membrane was partially resected and the CSF fistula was repaired via endoscopic endonasal approach. The pathological diagnosis was chordoma, and there has been no recurrence for three years after the surgery. It is necessary for chordoma to be considered as a differential diagnosis for cystic lesions of the clivus when the cyst membrane is enhanced by gadolinium.

Distal anterior cerebral artery(DACA)aneurysms are relatively rare. The detection of the surgical trajectory of DACA aneurysmal clipping is difficult because DACA aneurysms are located at various sites in the ACA. The purpose of this study was to evaluate the effectiveness of intraoperative use of color Doppler ultrasonography for the surgery of DACA aneurysms. DACA aneurysms of ten patients(three men, seven women;64.5 years old on median)were examined using intraoperative color Doppler imaging(CDI), which was performed before microscopic procedures, to detect the location of the aneurysms. Among them, six patients had ruptured aneurysms with diameters ranging from 2.5 to 10.8mm, and four of them had intracerebral hematomas. All the aneurysms and surrounding arteries were clearly detected using CDI. Moreover, in larger aneurysms, blood flow dynamics inside the aneurysm were also observed using CDI. As a result, we concluded that the intraoperative use of color Doppler ultrasonography was effective of detecting the trajectory for the DACA aneurysms without causing any damage to the brain by redundant dissections.

A rare case of a traumatic middle meningeal arteriovenous fistula on the side of the head opposite to the injured side was reported. A 21-year-old man was admitted to our hospital after a traffic accident in which the right side of his head was hit. CT scans and MR images on admission showed a right temporal bone fracture, traumatic subarachnoid hemorrhage, and a left frontal lobe contusion. Three months after the head injury, he complained of tinnitus and exophthalmos. One year after the head injury, left external carotid angiograms showed a dural arteriovenous fistula fed by the left dilated middle meningeal artery and draining into the middle meningeal vein. Early filling of the sphenoparietal sinus, cavernous sinus, superior ophthalmic vein, and the cortical vein were also detected. Transarterial embolization of the left middle meningeal fistula was performed, resulting in the disappearance of the lesion. The postoperative course was uneventful.

A rare case of cerebral venous thrombosis associated with thrombocythemia is reported. A 47-year-old man presented with headache, papilledema, and diplopia. Complete blood count showed an increased number of platelets. MR images and venography showed the thrombosis from the superior sagittal sinus (SSS) to the bilateral transverse sinuses (TS). The patient was treated with thrombolysis, continuous heparin infusion, and oral warfarin. On day 2, angiography demonstrated partial recanalization of the SSS and the left TS. Since CSF pressure was 30 cmH2O at day 11, a spinal drainage catheter was installed. Nevertheless, the patient presented with left hemiparesis, seizure, and loss of consciousness on day 12. Angiography revealed thrombosis from the SSS to the left TS and the right sigmoid sinus. Mechanical thrombolysis with a balloon was performed, and partial recanalization was obtained. In order to control the intracranial pressure, barbiturate coma therapy was performed for 1 week. On day 19 aspirin therapy was initiated become of continuous thrombocythemia. On day 25, the patient recovered completely. This case suggests that thrombocythemia may be able to cause refractory cerebral venous thrombosis.

A rare case of meningitis complicated by brainstem infarction is reported. A 64-year-old previously healthy female was admitted to our hospital because of a 1-week history of fever and headache. Cefdinir was orally administered for several days before admission. Analysis of cerebrospinal fluid (CSF) on admission showed a white blood cell (WBC) count of 9,013 cells/ micro/(97% polynuclear cells), a protein level of 212.8 mg/d/, and a glucose level of 3 mg/d/. CSF culture was negative for bacteria, including tubercle bacilli, and fungi. A brain computed tomography (CT) scan on admission showed acute hydrocephalus. Six hours after admission the patient developed tetraplegia. Diffusion-weighted magnetic resonance (MR) images on day 2 revealed elevated diffusion coefficients with high signal intensity in the pons and the medulla oblongata. MR angiography demonstrated a narrowing change of the cerebral arteries. Followup MR angiography two months after admission showed normalization of the cerebral arteries. The patient remained tetraplegic at eight months after admission. We speculated that brainstem infarction in our case might have been caused by vascultis or brain edema.

Occurrence of a mycotic aneurysm extracranially is extremely rare. We report our experience with a case of mycotic aneurysm that occurred in the external carotid artery accompanying infectious endocarditis. The case was a 33-year-old male. He visited our hospital with principal complaints of weakness in the lower left side and visual difficulty. Multiple cerebral infarctions were noted in a head MRI. In addition, vegetation was noted on the mitral valve in an echocardiogram, and the patient was admitted to cardiology for infectious endocarditis. Aneurysms were noted in the external carotid artery and the posterior cerebral artery in a cerebral angiogram performed before valve replacement. After administration of antibiotics for 5 weeks, radical surgery was performed for the external carotid artery aneurysm that had remained unchanged. With a satisfactory postoperative course, the patient was able to walk independently after mitral valve replacement and was discharged. We have scoured the literature with regard to mycotic aneurysm occurring extracranially and have studied this case because of this characteristic. When performing cerebral angiography to search for a mycotic aneurysm, the area outside the cranium as well as inside must be closely examined.

Spontaneous spinal epidural hematoma (SSEH) is a rare clinical entity. Although approximately 500 cases have been reported, controversy exists concerning timing of the treatment and the validity of decompression surgery. We recently encountered four cases of SSEH. Evacuation of the hematoma was carried out in two patients with severe or persistent neurological deficits. Other two patients were treated conservatively because of the rapid resolution of the symptoms. All four patients improved after the treatment; three patients fully recovered and one patient required rehabilitation for moderate quadriparesis. Many previous reports recommended decompression surgery within 48 hours after the onset, however, one patient in our series fully recovered after surgery 4 days after the onset. We reviewed 183 operative cases of SSEH with incomplete neurological deficits in the literature and found that 93% of the patients who underwent surgery more than 48 hours after symptom onset showed good neurological recovery. Conservative treatment should be undertaken for rapidly improving patients, but surgical intervention should be considered in symptomatic patients regardless of the time from the onset.

We reported a rare case of cervical glioblastoma with intracranial dissemination at an early stage of clinical course and reviewed the literature. An 8-year-old girl presented with failure of vision 3 months prior to admission to our hospital. Neurological examination on admission disclosed no definitive abnormalities except for bilateral visual disturbance and optic atrophy. Cranial MR images revealed a homogeneously enhancing tumor in the left sylvian fissure. Multiple spotty T2-hyperintensity lesions without contrast enhancement were also disclosed in bilateral cerebellum. Spinal MR images showed an enhancing tumor at C7 and tiny enhancing lesions on the surface of T11. The patient underwent an uneventful excision of the exophytic tumor at C7. The histological diagnosis was glioblastoma. The enhancing tumor in the left sylvian fissure treated by Linac stereotactic radiotherapy with a marginal dose of 38.4Gy in 12 fractions has diminished, whereas the residual tumor at C7 remained unchanged after radiation of 44Gy. In contrast, the multiple spotty lesions without contrast enhancement dispersedly spread in the cerebellum and infiltrated into brain stem despite 4 courses of chemotherapy using ifosfamide, cisplatin, and etoposide. Stereotactic biopsy of the multiple spotty lesions in the cerebellum was performed. Histological examination revealed anaplastic astrocytoma. The patient died 2 weeks after the biopsy despite additional chemotherapy and focal irradiation to the cerebellum. Early detection and selection of optimal therapeutic strategies are important in management of spinal glioblastoma with subarachnoid dissemination, since neuroradiological findings and therapeutic sensitivity are varied according to differentiation of disseminated tumors.

We reported a rare case of supratentorial primitive neuroectodermal tumors (sPNET) and reviewed the literature. A 15-year-old girl presented with a one-month history of headache and vomiting. CT scans showed a huge, solid and cystic tumor with calcification, occupying the left anterior cranial fossa. The solid portion of the tumor was hypointense on T1-weighted images, slightly hyperintense on T2-weighted images, hyperintense on diffusion- weighted images, isointense on fluid-attenuated inversion recovery (FLAIR) images, and strongly enhanced after administration of contrast medium. The expansile tumor had a broad attachment to the dura matter of the anterior cranial fossa. The patient underwent an uneventful extirpation of the tumor. Microscopically, the solid tumor contained small, round poorly-differentiated cells with pleomorphic nuclei and brisk mitotic activity. The tumor cells were immunoreactive for synaptophysin and GFAP, whereas lack of MIC2 gene product expression was confirmed using the monoclonal antibody 12E7. The MIB-1-positive rate was 43%. The histological diagnosis was sPNET. Postoperatively, a dose of 30.6Gy was administrated to the whole brain and a boost of 19.6Gy to the T2-hyperintensity lesion. The patient successively received a dose of 30.4Gy to the whole spine and Linac stereotactic radiotherapy with a marginal dose of 16.8Gy at the tumor bed. Three months after radiotherapy the patient received chemotherapy using carboplatin and etoposide. Follow-up MR images showed no evidence of recurrent tumor 5 months after the radiochemotherapy. On the basis of MR findings on both diffusion-weighted and FLAIR images, preoperative diagnosis of sPNET may be important for choosing appropriate therapeutic strategies for this tumor.

A 29-year-old woman presented with a primary meningeal melanocytoma of the left middle fossa manifesting as headache and nausea. Computed tomography (CT) with contrast medium demonstrated a clearly demarcated, homogeneously enhanced high density area surrounded by a cyst in the left temporal lobe. Magnetic resonance (MR) imaging showed the mass as a slightly high signal intensity area on the T1-weighted image and as a low signal intensity area on the T2-weighted image. Cerebral angiography revealed shift of the middle cerebral artery but no tumor stain. The solid part of the tumor had rapidly increased in size with reduction of the cyst 3 months later. Left frontotemporal craniotomy disclosed a clearly demarcated jet-black tumor attached to the dura. The black-colored lesion in the dura and the bone extended to the skull base, so malignant melanoma was a possibility. The solid part of the tumor was gross totally removed, and the dura and the skull bone were preserved. Histological examination of the tumor specimen revealed meningeal melanocytoma. Melanophages were present in the specimen of the black-colored lesion in the dura and the bone, but no neoplastic infiltration was present. The postoperative course was uneventful, and the patient's headache and nausea disappeared. CT and MR imaging taken 1 month later confirmed total removal of the tumor. No recurrence has been observed for 2.5 years after surgery. Preoperative differentiation of meningeal melanocytoma from malignant melanoma is difficult, but the primary goal of therapy is gross total resection of the solid part of the tumor irrespective of tumor type.

Orbital neuroma is a rare disease accounting for a certain percentage of all orbital tumors. However, because of the anatomical features of the orbit, the origin of the tumor has been diagnosed in only a few cases. The authors report a case of orbital neuroma arising from a short ciliary nerve that was confirmed during surgery. The patient was a 72-year-old female. She visited our hospital with complaints of left visual disturbance, exophthalmus and diplopia. Neurological examination on admission also revealed Marcus gunn pupil sign. CT scan and MRI imaging showed a left orbital tumor located along the superior surface of the optic nerve and adjacent to the posterior pole of the eye ball. She underwent superior orbitotomy through a transcranial approach. The tumor was encapsulated and adhered tightly to the sclera, short ciliary nerve, and optic nerve. For this reason, it was removed without a part of the adhered capsule. Since histological examination revealed neuroma, the tumor was diagnosed as short ciliary nerve neuroma. Postoperatively no additional deficits occurred. The exophthalmus, diplopia and Marcus gunn pupil sign disappeared and visual acuity was improved after the surgery. In such a case of short ciliary nerve neuroma, it is possible to remove the tumor without any neurological deficit, if careful consideration of microsurgical anatomy is made.

We report a case of large clival chordoma. The patient was a 56-year-old male who was admitted to our hospital with left eye ptosis and diplopia of 2 months duration. On admission, neurological examinations revealed oculomotor nerve palsy of the left eye. Skull radiographs with polytomographs demonstrated marked destruction of the clivus. A plain computed tomography (CT) scan revealed a large iso-attenuated mass in the clivus, extending anteriorly into the sphenoidal sinus, superiorly into the suprasellar cistern, bilaterally into the petrous apex, posteriorly into the prepontine cistern and caudally into the foramen magnum. An enhanced CT scan demonstrated a slightly enhanced tumor. A high-resolution bone-window CT scan revealed marked destruction of the clivus and bilateral petrous apex. Magnetic resonance imaging (MRI) scans disclosed a large enhanced mass extending superiorly into the suprasellar cistern, bilaterally into the petrous apex and inferiorly into the foramen magnum. The tumor extended so widely that we decided on a one-stage operation via a transsphenoidal sublabial transseptal approach and transoral transpalatal approach. At surgery, we employed a neuronavigator and Codman 4-mm rigid neuroendoscope with 0 degree, 30 degrees and 70 degrees angled lenses. The tumor was very soft and suckable, and could be easily removed by applying CUSA, a pituitary curette and suction. The neuronavigator was particularly useful because the surgeon had a real-time two-dimensional representation of the position of the tip of this device in the corresponding imaging space intraoperatively. The neuroendoscope also proved useful, since remnant tumor tissues that could not be seen under an operating microscope were frequently recognized near or around the entrance of the tumor cavity, cavernous sinus region and petroclival junction area. The surgeon was able to remove these remnants safely by checking on the neuroendoscope monitor. The tumor was excised completely. The dead space of the tumor cavity was reconstructed using a free rectus abdominis muscle flap. Postoperatively, cerebrospinal fluid leakage and meningitis were recognized, but improved following spinal drainage for one week and intrathecal injection of antibiotic. The oculomotor nerve palsy of the left eye also showed good recovery at one month after the operation. Recently, skull base surgery has undergone considerable developments. Neuroendoscopes and neuronavigators are very helpful for the neurosurgeon in performing skull base tumor surgery safely and with precision, although further instrument modifications are needed.

We described an autopsy case of a ruptured aneurysmal subarachnoid hemorrhage treated with endovascular embolization by interlocking detachable coils. An 85-year-old male presented with sudden onset of severe subarachnoid hemorrhage. Cerebral angiogram revealed a right internal carotid-posterior communicating artery aneurysm. Post-operative angiogram revealed complete obliteration of the aneurysm, except for its orifice. Following the embolization of the aneurysm, tissue plasminogen activator was intrathecally perfused for anti-vasospasm treatment. Follow-up angiogram showed stable obliteration of the aneurysm, and no particular findings of cerebral vasospasm. The patient had been recovering without any neurological deficits, but died from pneumonia on the 25th day after the embolization. Autopsy findings revealed the disappearance of the subarachnoid hemorrhage, and no visible finding of cerebral infarction or edema. The inner lumen of the aneurysm was occupied by a mixture of the coils and the clots. The surface of the embolized coils was directly observed through the orifice of the aneurysm without any membranous substance from the inner lumen of the internal carotid artery. This pathological finding is different from the previously reported animal models in which the surface of the embolized coils was covered with endothelial membrane 2 weeks after embolization. Further examinations are required to clarify the pathogenesis of the endothelial regrowth.

We report a case of large cystic acoustic neurinoma. A 52-year-old male was admitted to hospital with a history of progressive dysphagia, gait disturbance and diplopia for 2 months. On admission, neurological examinations revealed Bruns' type nystagmus to the left side, hypesthesia in the distribution of the second and third divisions of the left trigeminal nerve, and partial paresis of cranial nerves IX, X, and XII on the left side, and truncal ataxia. A pure-tone threshold audiogram indicated the presence of 32 dB hearing loss in the left ear. Speech discrimination was 80%. Caloric vestibular responses were absent on the left side. Skull radiographs with polytomographs of the internal auditory canal (IAC) were normal. Bony changes in the IAC were not found by high-resolution bone-window computed tomography (CT) scan. A plain CT scan revealed a large low-attenuated cystic mass in the left cerebellopontine angle (CPA), which was associated with displacement of the fourth ventricle. An enhanced CT scan demonstrated a thin rim-enhancement in the cyst wall. Magnetic resonance imaging (MRI) scans disclosed a large rim-enhanced cystic mass extending superiorly into the tentorial incisura and inferiorly into the foramen magnum. At surgery via a left suboccipital approach, a large cystic mass was found at the left CPA arising from the VIIIth nerve, and compressing the Vth, VIth, VIIth and lower cranial nerves. The cyst was filled with a xanthochromic fluid and was firmly attached to the internal auditory meatus (IAM). However no tumor extension into the IAM was confirmed. The tumor was excised completely. The postoperative course was uneventful, except for impairment of the VIIth and VIIIth nerves. At 6 months after the first operation, the facial nerve had improved up to grade III (Hause-Brackmann stage). Histological examinations revealed a typical benign acoustic neurinoma with predominant representation of Antoni B tissues. The cyst wall contained numerous abnormal sinusoid and telangiectasia-like vessels which showed occasional thromboses. The vessel walls displayed endothelial proliferations and were frequently hyalinized. Hemosiderin deposits and hemosiderin-containing phagocytes were also found near these vessels. Myxoid degeneration and necrosis were evident in vast areas. These degenerative changes appeared to be the principal causes of the large cystic formation. 16 cases including our case have been reported. The broad characteristics of the clinical symptoms and radiological findings of these tumors are discussed.

We report a case of distal posterior inferior cerebellar artery (PICA) aneurysm associated with acute subdural hematoma (SDH). The patient was a 68-year-old female who was found unconscious at home and transferred to the emergency medical center in a state of deep coma. Her consciousness on admission to the center was 200P (Japan coma scale), E1V1M2 (Glasgow Coma Scale), and the Hunt & Kosnik grade was grade IV. She was in a state of decerebrate condition. Computed tomography (CT) scans revealed diffuse subarachnoid hemorrhage that was located mainly in the posterior fossa, as well as intraventricular hemorrhage in the third and fourth ventricles. It also disclosed an intracerebellar hematoma (ICH) of the vermis and an acute SDH of the left posterior fossa. The first cerebral angiographic examinations on admission demonstrated no aneurysm. However, emergency surgery was performed immediately in order to improve her poor condition. Ventricular drainage and removal of the acute SDH were carried out. Postoperatively, her consciousness improved gradually to 20P. Ventricular peritoneal shunt was performed three weeks later. Her consciousness improved up to 3P and she showed only slight truncal ataxia. She was admitted to our hospital for rehabilitation at two months after the first surgery. Repeated angiography was performed and demonstrated an aneurysm in the telovelotonsillar segment of the left PICA. The aneurysm was successfully clipped via a midline suboccipital approach. Her postoperative course was uneventful, and she continues to undergo rehabilitation. Aneurysms of the posterior fossa associated with acute SDH are extremely rare. Only two cases have been reported for distal PICA aneurysm cases. The CT scans in our patient revealed not only SAH but also SDH in the posterior fossa and ICH in the vermis. Over 100 cases of distal PICA aneurysms have been described in the literature. We analyzed the relationship between the portions with the ruptured aneurysms and CT findings. Aneurysms which were located at the proximal portion of the distal PICA mainly showed SAH and IVH. On the other hand, ICHs of the vermis and cerebellum were characteristic CT findings of ruptured aneurysms which were located more distal to the telovelotonsillar segment, and were evident in 14% of cases of such aneurysms. ICH and SDH were not found in aneurysms which were located in portions more proximal to the telovelotonsillar segment. These characteristic findings were related to the complex anatomical courses of the PICA. The distal portions of the PICA run between the vermis and cerebellar hemisphere, so that if an aneurysm ruptures at these portions, ICHs in the vermis and cerebellum tend to occur. In cases such as ours, because of the characteristic CT findings, effort to detect a distal PICA aneurysm should be made at first surgery, along with ventricular drainage and removal of the SDH. The surgical procedures and outcome of cases with distal PICA aneurysms are also discussed.

We report a rare case of a giant thrombosed fusiform aneurysm at the branch of left middle cerebral artery presenting with intramural hemorrhage of the aneurysm. A twenty-year-old man with familial and past history of migraine presented sudden temporalgia on August 13, 1995. Computed tomography (CT) scan on the day of the first attack revealed a well delineated high density area at the left Sylvian fissure, 2.5cm in diameter. Angiogram showed avascular area corresponding to the lesion, but no visualization of the aneurysm. On October 18, this patient presented sudden temporalgia again. CT scan on the day of the second attack indicated new intramural hemorrhage and surgery was performed on October 31. No evidence of subarachnoid hemorrhage was shown during the operation, and the lesion was proven to be a thrombosed fusiform aneurysm at the branch of the middle cerebral artery. The parent artery was clipped at both proximal and distal sides of the aneurysm, and the aneurysm was totally removed with success. Histological finding further supported the idea that the attacks mentioned were due to intramural hemorrhage of the thrombosed aneurysm. Postoperative course was uneventful and the patient was discharged without any neurological deficit. Intramural hemorrhage of a giant fusiform aneurysm is relatively rare, only reported in several autopsy cases. Furthermore, we failed to discover any comparable cases of giant fusiform aneurysm presenting symptoms directly caused by intramural hemorrhage of the aneurysm.

We report a case of intraorbital conjunctival cyst following a penetrating orbitocranial injury. The patient was a 28-year-old male who was hospitalized with exophthalmos, retrobulbar pain and upper gaze disturbance of his left eye. When he was 4 years old, a thin iron rod had penetrated intracranially through the inner angle of his left orbit. He was hospitalized and treated conservatively for about two weeks. The left eye ball was intact and visual acuity was normal, although bloody fluid had continuously flowed out from the left inner angle of the conjunctival wound for a few days. He had been febrile to 39 degrees C and complained of headache for one week. Subsequentry, the symptoms gradually improved through conservative therapy. When he was a junior high school student, he noticed exophthalmos of his left eye. However, he had never been examined closely, until he was 28 years old. We suspect that he had suffered from meningitis caused by the penetrating orbitocranial injury, and had fortunately improved under the conservative therapy. On admission to our hospital, a craniogram showed fracture of the left orbital roof, and coronal and three-dimensional computed tomography (CT) scans clearly demonstrated the orbital fracture. CT revealed a cystic mass in the retrobulbar space, and a porencephalic cyst in the medial basal frontal lobe. On magnetic resonance imaging (MRI) scans, both cysts were of low intensity on T1-weighted imaging, and of high intensity on T2-weighted images. Coronal and sagittal MRI scans showed that the two cysts were connected with each other through the fracture in the orbital roof. We diagnosed therefore that the orbital cyst was a herniated porencephalic cyst of the frontal lobe. Surgery was performed by a transcranial approach. The porencephalic cyst adhered to the fractured lesion of the frontal base but did not extend into the orbita. The intraorbital cyst was totally removed by opening the orbital roof including the fractured lesion. The cyst contained milky fluid. Postoperatively, the exophthalmos, retrobulbar pain and upper gaze disturbance showed gradual improvement. On histological examination, the cyst was found to be lined by non-keratinized stratified squamous epithelium and was diagnosed as a conjunctival cyst. This case was considered to be one of traumatic conjunctival cysts caused by a penetrating orbitocranial injury. Orbital conjunctival cysts have been reported to comprise about 10% of orbital epidermoid and dermoid cysts. Of these cysts, traumatic conjunctival cysts are rare, and only a few cases have been described. The etiology and therapy of orbital conjunctival cysts are discussed.

We present here an interesting case of multiple dural arteriovenous shunts (dAVS) in different locations at the same time. There have been very few reports on multiple dAVS. A 63-year-old man was admitted with a sudden onset of headache and vomiting. CT scan showed a typical subarachnoid hemorrhage (Fisher Group 3). Cerebral angiogram (6 vessel study) revealed two dural arteriovenous shunts at the same time. One was located on the anterior fossa fed by the anterior ethmoidal artery, and the other was located on the posterior fossa near the marginal sinus fed by the left ascending pharyngeal and occipital arteries. At first, transarterial embolization was performed for dAVS located on the posterior fossa. Radical operation was performed for both anterior and posterior fossa dAVS. Both dAVS had disappeared on postoperative angiograms.

We reported a very rare case of an epidural hematoma soon after nose blowing. A 22-year-old male visited our hospital complaining of severe headache and nausea soon after he blew his nose. Thirteen years ago, he had a ventriculo-peritoneal (V-P) shunt operation for a pineal region tumor which had not recurred after irradiation. His left auditory tube had been patent. He hit his head about 3 months ago. On his arrival, his consciousness was almost clear but we observed slight right hemiparesis. Computed tomography of his head obtained on the first day showed the air in the hematoma in the left parietal epidural space which penetrated his petrosal bone from the mastoid air cells. Removal of his epidural hematoma was performed the next day and there was no abnormality of his parietal bone, dura and meningeal arteries. We supposed that nose blowing was what triggered his epidural hematoma. From pressure of nose blowing, the air of his nasopharyngeal space passed through his patent auditory tube into the tympanic cavity, and entered into the epidural space penetrating a microfracture or dissociation in the petrosal bone. In addition to this, V-P shunt system and the looser adhesion of dura to the skull in the young promoted entrance of air. Associated with formation of epidural hematoma in this case were four factors, "patency of auditory tube", "defect or microfracture of petrosal bone", "V-P shunt", "younger age" and triggered by nose blowing.

We report a case of triple intracranial tumors of different cell types without phacomatosis. The patient was a 77-year-old female who was hospitalized with left hemiparesis and vomiting. Computed tomography (CT) scans revealed a large tumor mass in the right frontal lobe and relatively small tumor masses in the medial right frontal and parietal lobes. Other tumors were also detected in the sella turcica, left sphenoidal wing, left anterior clinoidal process and left cerebellar convexity. This case was considered to be one of metastatic brain tumors, and surgery was performed for the right frontal tumor because of its mass effect. The tumor was so highly vascular that it could not be totally removed. Postoperatively, the mass effect showed a gradual increase on CT scans because of intratumoral hemorrhage and peritumoral edema. The patient's consciousness level gradually fell, and she died of pneumonia and cardiac insufficiency 1 month after the operation. The surgical specimen of the tumor was diagnosed as glioblastoma multiforme by histological examination. At autopsy, the small tumors in the medial frontal lobe and parietal lobe were found to be clearly separated from the large right frontal tumor and were diagnosed as multicentric glioblastoma multiforme. The sellar tumor revealed chromophobe pituitary adenoma and was diagnosed as a prolactinoma by immunohistochemical examination. The tumors in the left sphenoidal wing and left cerebellar convexity were diagnosed as transitional meningiomas. Multiple primary intracranial tumors of different cell types without phacomatosis are relatively rare, but almost 100 reported cases could be found in the literature.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors report an experimental trial of intra-aneurysmal occlusion using fibrin glue. Nowadays, with the development of microsurgical techniques and aneurysmal clips, results of direct radical operations have been improving. But quite a few aneurysms cannot be clipped because of their size, location, broad neck etc. Some authors have treated these aneurysms with innovative techniques (detachable balloon techniques etc). In these methods, the occlusive state of the aneurysms is not always obtainable because of the size of their neck. Besides, it is not always possible to preserve the parent arteries of the aneurysms. Experimental aneurysms in cervical carotid arteries of dogs are treated by direct injection with fibrin glue. During its injection, influx of fibrin glue was prevented by occlusion of the aneurysmal orifices with inflated polyethylene angioplastic balloons. The aneurysms which were completely (100%) filled by the injection of fibrin glue (100% infused group) were totally obliterated in 10 (71%) of the 14 cases. The parent arteries were completely preserved in all instances. Follow-up study demonstrated satisfactory maintenance of this occluded state in the aneurysms in the 100% infused group. In completely occluded cases, all aneurysms maintained this state. On the other hand, 1 of the 4 incompletely obliterated aneurysms recanalized partially. These occluded aneurysms were studied by a light microscope (LM) and a scanning electron microscope (SEM). At day 7 after the occluding procedure, the margin of the aneurysmal orifice was covered by a layer of fibroblasts. At day 21, almost half of the aneurysmal cavity had been substituted with connective tissue. The orifice of the aneurysms was covered with an endothelial layer.(ABSTRACT TRUNCATED AT 250 WORDS)

Continuous monitoring of the intracranial pressure and ventricular infusion test were carried out in 13 cases in which normal pressure hydrocephalus (NPH) was suspected. The infusion test was performed by intraventricular bolus injection of 8 ml of saline. The result was collated with the effect of shunting operation, which was judged by means of the improvement in the clinical symptoms and the amplitude of contingent negative variation. The excellent effect of shunting operation was obtained in the patients who showed the T of more than 200 sec, the compliance of less than 1.0 ml/mmHg, the conductance to outflow of less than 0.8 ml/mmHg/min and CSF outflow resistance of more than 15 mmHg/ml/min. In 3 cases out of the 5 effective cases, A or B wave was seen. However, appreciable variation of the values was shown among the cases so that it was concluded that the all-round-consideration must be done to select the case for the shunting operation with the findings in RI-cisternography, pneumoencephalography, computerized tomography and so on. This fact might indicate the existence of the complicated pathophysiology in NPH resulted from not only the impairment of cerebrospinal fluid circulation but also the disturbance of cerebral blood flow, changes in plasticity of the brain and so on.

Spontaneous arterio-venous fistula (AVF) of the external carotid system is very rare. We successfully treated such a case by the detachable balloon method. The patient, a 2-year-and-9-month-old female who has no history of trauma had a pulsating mass at her right retroauricular region six months after birth. On admission to our clinic she was neurologically free except the pulsating mass (2 X 3 cm) with bruit and thrill. Selective right external carotid angiography revealed a high-flow simple AVF from internal maxillary artery to jugular vein. The normal blood flow of both the external and internal carotid system was decreased. Under local anesthesia, non-detachable balloon catheter was inserted to the internal maxillary artery by the transfemoral approach and inflated at the proximal side of the orifice of AVF until the vascular murmur in the neck disappeared. The balloon catheter was then exchanged with a detachable balloon catheter (Debrun, No. 9) which was inflated by silicone (0.4 ml), and was detached successfully. Follow-up angiography 1 year after the treatment revealed no recurrence of the fistula and almost branches of external carotid artery such as middle meningeal artery, occipital artery, superficial temporal artery and facial artery were clearly seen.

Two cases with epidermoid and one case with dermoid in the 4th ventricle were treated in our clinic during the last one year. The clinical findings in these three cases were described, and dermoid and epidermoid tumors in the 4th ventricle were discussed dealing with the incidence and the characteristic features of the findings in CT scanning. The correct diagnosis of both epidermoid and dermoid in the 4th ventricle was done by CT-scanning which showed an irregular low density area of EMI No. -4 approximately 12 in the posterior fossa without any contrast media enhancement. The low density lesion could be differentiated by both angiogram and ventriculogram from arachnoid cyst, ependymoma, cystic astrocytoma and cystic hemangioblastoma in the 4th ventricle. Total removal of the tumor was performed on 2 cases, and a part of the tumor capsule attached to the medulla oblongata was left in the other case. All patients returned to their own job after operation.

A medulloblastoma in a 7-year-old girl showed complete remission after the initial radiotherapy of 5,000 rad. But she had three episodes of recurrence in the cerebellum and in the spinal cord, and was treated by additional radiotherapy for the lesions 3,000 to 5,000 rad. When the total cerebellar tumor dose became 13,300 rad, a fatal intratumoral hemorrhage occurred. Autopsy revealed a massive intratumoral hematoma and thin-walled tumor vessels which might be designated as "sinusoid" or "telangiectasia" microscopically. The authors proposed a possibility that the thin-walled vessels and the high dose of radiotherapy caused the hemorrhage.

From April, 1978 through December, 1984, computed tomographic (CT) findings were carefully examined in 34 cases of initial subarachnoid bleeding due to a single ruptured aneurysm in the posterior fossa. All of the patients were hospitalized within 3 days of the onset of symptoms. High-density areas, which indicate the presence of subarachnoid clots, were evaluated in the interhemispheric and Sylvian fissures and the interpeduncular, prepontine, ambient, and quadrigeminal cisterns. The CT data suggest that hematomas in the four cisterns are thicker than those in the supratentorial subarachnoid spaces. Only one patient had an intracerebral hematoma. Hydrocephalus accompanied aneurysms of the posterior fossa more frequently than those of the anterior circulation.

We have introduced concept of "chemical" embolization and have tried to develop a new agent which would enable us to embolize the lesion with one-shot injection. Such an agent must be able to occlude diffusely the lesion distal to the catheter. This has made it mandatory to develop a new catheter which can be introduced into the vessel as close to the lesion as possible with fewer risks of clot formation and/or vessel damage. A new superselective balloon catheter for angiography and infusion of liquid embolizing materials has been developed. This catheter consists of a proximal relatively stiff silicone catheter, a short distal thin-walled flexible silicone catheter and silicone balloon. These three silicone components are connected by silicone adhesives. The distal catheter allows us to catheterize fine arteries such as lenticulostriates, while the proximal catheter assures easy manipulation. This balloon catheter can be used for superselective angiography and infusion of liquid embolizing materials. It has been used on nine patients; one with a dural arterio-venous malformation (AVM), four with meningiomas, and four with brain and spinal cord AVMs. In the case of dural AVM and meningiomas, it was possible to easily introduce into the middle meningeal artery distal to the foramen spinosum. In addition, in one of the cases of meningioma, we were able to catheterize one of the main feeding pedicles beyond the pterion. Chemical embolization was carried out in 5 cases with good results. In the case of brain and spinal cord AVM, useful information was obtained from the superselective angiography.(ABSTRACT TRUNCATED AT 250 WORDS)

A 37-year-old man was admitted to our clinic 3 hours after the onset of cerebrovascular accident with right hemiparesis and total aphasia. On admission, we started combined administration of mannitol, vitamin E, phenytoin (Sendai Cocktail) and perfluorochemicals to protect ischemic brain. Left cerebral angiography revealed occlusion of the left middle cerebral artery involving its perforating arteries. Following the performance of angiography, vascular balloon catheter was introduced into the embolus, and fibrinolytic agent (urokinase) was continuously injected. Soon after the injection of 240,000 unit urokinase, recanalization of left middle cerebral artery was shown by repeated cerebral angiography performed 5.5 hours after the onset. On his clinical course, left hemiparesis and aphasia were improved step by step, and 1 week later, he could walk by himself with minor neurological deficits. Further examination revealed that myxoma was located on left atrium by echocardiography. Within 1 week, the patient was transferred to cardio-surgical unit, and myxoma was successfully removed. Now he is in good health and has returned to his job. Usually cerebral embolisms result from atrial myxoma cause severe cerebral infarction. Here we reported a case of cerebral embolism by myxoma and recanalized using fibrinolytic agent by balloon catheter injection. The damage will be reduced if the duration of occlusion is limited, so this method will be helpful to treat cerebral embolism.

We report a survival patient with hemorrhage in the quadrigeminal plate and discuss the literature of midbrain hemorrhage. A 13-year-old boy developed severe headache and vertigo on April 1st, 1983. On admission, he was comatose and tetraplegic with bilateral facial palsy and total ophthalmoplegia. CT scan revealed a hemorrhage in the midbrain and ambient cistern, but vertebral angiogram no abnormal vessels. Seven hours after admission, continuous ventricular drainage was performed. Disturbance of consciousness, ophthalmoplegia and speech disturbance were gradually improved. CT scan with contrast medium 3 weeks after admission showed a small high density spot in the right quadrigeminal plate. It might be suggested that this spot was the bleeding point and was probably a cryptic microvascular malformation. At the discharge only a minimal limitation of eye ball movement was left.

The interstitial pressure of the brain was measured with wick catheter by Lassen in 1972. But original wick catheter inserted into the brain tissue does not always measure the real interstitial pressure as indicated by experimental results of Brodersen, because, the interstitial pressure is always affected by solid pressure such as cells in the brain tissue, in the condition of which surrounded by positive CSF pressure in the semiclosed skull box. It is not yet clarified what kinds of the pressure are measured by wick catheter method in the brain tissue. The size of wick catheter is 300-500 times as large as the width of interspace of the brain tissue and the catheter is easily obstructed by brain tissue. Therefore, a new, modified wick catheter is made for improvement of these problems which is observed by using original wick catheter. The new, modified catheter has 0.4 mm inside diameter and 10 cm length. The tip of catheter is closed and 6 small side holes(0.1 mm0)are made. Inside the catheter, several pieces of 0.04 mm diameter nylon threads are inserted as shown in figure 1, and the catheter is filled up with the cerebrospinal fluid. In this paper, the structure of the new, modified catheter is demonstrated, and the brain tissue pressure is measured, comparing with the results of the original wick catheter to test the function of the new, modified catheter. The results of measurement of the brain tissue fluid pressure with the new, modified catheter are as follows; 1) The brain tissue fluid pressure is relatively constant and shows a positive pressure of 5.2 mmHg. 2) As there are few blocking effects in the catheter, the new, modified catheter is useful for the measurement of the brain tissue fluid pressure for a long time. 3) The brain tissue fluid pressure is not altered by the number's of nylon threads in the catheter at static condition, but movement of brain tissue fluid pressure with respiration is a little dumped by the increased conductancy with the numbers of nylon threads in the catheter. 4) The tissue fluid pressure affected by the viscosity and osmolarity of the fluid in the catheter, CSF should be used for correct measurement. According to these results, it might be concluded that the new, modified wick catheter is better than the original wick catheter regarding prevention of obstruction of the catheter by brain tissue fragments, artifacts which causet by movement of wick fibers, measurement of brain tissue fluid pressure for a long time and clarify the resistance of catheter to pressure conductancy.

A case of primary intracranial yolk sac tumor, the first known case growing in the frontal lobe, is compared with similar cases of suprasellar region. The case, 18-year-old female, suffered from headache, vomiting and visual disturbance for one month prior to the hospitalization. Plain CT scan demonstrated suppressed left anterior horn and normal density area in front of it. After injection of contrast medium, the area was enhanced distinctly. The left carotid angiography displayed a hypervascular mass in the suprasellar region and tumor stain was also seen in the capillary phase. Bilateral frontal craniectomy was performed and the tumor was almost totally removed macroscopically. The tumor situated in the left frontal lobe infiltrated into the optic nerve and a part of anterior cerebral artery. Histologically the tumor was diagnosed as yolk sac tumor according to Teilum's classification. There were stellate cells arranged in loose vacuolated network which formed cystic cavities and a complicated network of honeycomb with communicating cavities and extracellular PAS-positive hyaline globules. Glomerular-like structures (Schiller-Duval body) was also seen. Immunoperoxidase study clearly demonstrated the presence of intracytoplasmic alphafetoprotein granules in the tumor tissue. In radioimmunoassay, the level of the serum alphafetoprotein measured was two folds higher than that of the normal range, postoperatively. Although irradiation (local 3000 rads, whole 3000 rads) combined with chemotherapy (ACNU, Futraful), PSK had almost no effect. The effect of other chemotherapy (Cis-platin, VBL, Bleomycin) was indicated by the diminish size of the tumor. Five months after the onset, she was discharged with almost no neurological findings other than left visual loss. Pathological findings and clinical treatments were also discussed in detail.

Giant aneurysm of the posterior cerebral artery was very rare. The authors could seek only 6 cases in published literature. We experienced one case of the giant aneurysm at the posterior cerebral artery. The case was 25 years old female. She occasionaly complained of headache and nausea for 4 years before administration. Cerebral angiogram revealed a giant aneurysm of the right posterior cerebral artery with slightly dilated ventricle. CT scan revealed a ring shape high density area and its high density area enhanced by Conray infusion. A clipping of posterior cerebral artery at the just proximal point of the aneurysmal neck was done, because adhesion of the aneurysm to the brain stem was very tight and the aneurysmal neck was very broad. After the operation, giant aneurysm was not seen on both angiogram and CT scan. Patient did not complain of headache any more and any defect of the visual field.

Percutaneous embolization using a detachable balloon in six cases of vertebral fusiform aneurysm is reported. Location of these aneurysms were as follows; 5 aneurysms in the distal vertebral artery (2 proximal to the posterior inferior cerebellar artery; PICA, 2 distal to the PICA and 1 where the PICA was undetectable), and one aneurysm in the extracranial vertebral artery. Three cases suffered from subarachnoid hemorrhage (dissecting aneurysms) and other cases showed lower cranial nerve palsy (giant aneurysm) or posterior fossa ischemia. Most of the cases were treated immediately after conventional diagnostic angiography, especially those cases with subarachnoid hemorrhage (within 4 days after the last attack). Under local anesthesia, a catheter was positioned in the affected vertebral artery either trans-femorally or trans-axillary. The detachable balloon was placed proximal to the aneurysm and test occlusion was performed for 15-20 minutes (the tolerance test or balloon Matas' test). After it was confirmed that there had been no neurological deterioration, the vertebral artery was permanently occluded by detachment of the balloon. The procedure was successful in all cases. Thrombosis of aneurysms was confirmed either by follow-up angiography or by autopsy. However, two cases who were grade V (Hunt & Kosnik) at admission died of severe vasospasm. PICA was preserved through either ipsilateral or contralateral collaterals. Detachable balloon occlusion of the vertebral artery for fusiform aneurysm is thought to be less invasive, more indicative and a safer procedure compared to conventional surgical proximal occlusion therapy.

A 46-year-old female was transported to our clinic 4 hours after the onset of sudden headache and transient loss of consciousness. On admission, she was drowsy with slight left hemiparesis and anisocoria (left greater than right). The CT scan revealed a right subdural neurological deficit one month after the operation. the operation, we found that the hematoma was derived from a small meningioma attached to the dura at the middle temporal fossa. The meningioma was 1.5 cm in diameter. The patient was discharged without neurological deficit one month after the operation. Although glioblastoma and metastatic brain tumor are most common, meningioma is rare as a cause of intracranial bleeding. Among 69 cases of meningioma with intracranial bleeding reported previously, only 4 cases were accompanied with acute subdural hematoma.

The ideal treatment of cerebral arteriovenous malformations (AVMs) is thought to be the total resection of nidus. We have been reporting the importance of temporary occlusion of the feeding arteries with the aid of the brain protective substances to prolong the permissible time of occluding these arteries. Because of the difficulty of access to the feeding arteries, some cases are difficult or even impossible to operate. In this communication, four cases of AVM which were successfully resected utilizing intraoperative balloon occlusion of feeders under the administration of the brain protective substances are reported. Case 1. A 14-year-old female was admitted to our clinic because of subarachnoid hemorrhage with ventricular rupture and left cerebellar hemorrhage. Angiography disclosed a large left cerebellopontine angle AVM fed by left anterior inferior cerebellar artery (AICA) and left superior cerebellar arteries (SCAs). Prior to the operation, two balloon catheters were introduced via transfemoral approach; one into the AICA and the other into the basilar artery where left SCAs originated. To prolong the permissible time of occluding these arteries, "Sendai cocktail" (20% mannitol, vitamin E and dexamethazone) and perfluorochemicals were administered. Auditory brain stem response (ABR) was monitored continuously during the operation. The nidus was resected totally with safe using temporary inflation of these balloon catheters. The patient returned to normal life. Case 2. A 35-year-old male was admitted to our clinic complaining of the attack of generalized convulsive seizure.(ABSTRACT TRUNCATED AT 250 WORDS)

Thirty five cases of traumatic aneurysm of the cortical cerebral artery were reviewed in the literatures cited in the references. Five cases of them healed spontaneously without operative treatment (disappearing type), the other cases underwent direct operation of aneurysm, in spite of high operative moltality or mobility (deteriorating type). Recently four cases of traumatic aneurysm of the cortical cerebral artery were treated in our clinic. Three cases which had the aneurysm in the pericallosal artery (1 case) and middle cerebral artery (2 cases) respectively underwent radical operation for treatment as progressively deteriorating type and fourth case which had the aneurysm in the peripheral part of the frontopolar artery was treated by medication as the spontaneously disappearing type until the aneurysm disappeared on the angiogram. According to the review of literatures, it is the most important for the treatment of tramatic aneurysm to know whether disappearing type or deteriorating type, because deteriorating type had bad prognosis without radical operation and the prognosis of disappearing type was excellent without operation. Analysing the clinical signs and angiographical findings of the all cases, the authors found out some specific characteristics of the spontaneously disappearing type. are (1) The aneurysm is found in the relativery late post traumatic stage except for cases caused by penetrating wound, (2) The irregular shape, uneven opacity of the aneurysm without clear neck connecting with pearent artery on angiography, (3) Shape and size of the aneurysm in follow up angiogram (two weeks or more) became smaller, (4) Around of aneurysm, there are not any kind of intracranical hemetoma. According to these results, differential diagnosis between spontaneously disappearing type and deteriorating type was done in the author's four cases and the three cases of deteriorating type were relieved by radical operation without any postoperative disability and one case of spontaneously disappearing type was treated by medical treatment until disappear of aneurysm. It is concluded that traumatic aneurysm of the cortical cerebral artery is relative rare and it is important to know whether deteriorating type or spontaneously disappearing type in order to get excellent results.