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The evaluation of the response to radiation therapy in brain tumor patients is a major and an important issue. Although CT and MRI can measure changes in tumor size, it is difficult to use these imaging methods to evaluate the viability or the proliferation activity of a tumor. In this study, we investigated the metabolite changes in glioma patients using 1H-MRS from before to after radiation therapy, to see whether or not early metabolic changes occur during therapy. Seven patients with histologically proven glioma (1 astrocytoma, 1 anaplastic astrocytoma, 2 oligoastrocytoma, 1 oligodendroglioma, 2 glioblastoma) were examined by means of 1H-MRS using a point-resolved spectroscopy (PRESS) sequence with a repetition time of 2,000 ms and echo times of 68 ms, 136 ms and 272 ms. The 1H-MRS was evaluated by both the spectrum pattern and the quantification of the metabolites. As to radiation therapy, each patient received a total dose of 64.8 Gy (1.8 Gy/fraction) with a 10-MeV linear accelerator. The results revealed that the concentration of choline-containing compounds (Cho) was 4.55 +/- 1.08 mmol/kg wet weight before radiation therapy and was reduced to 2.69 +/- 0.56 mmol/kg wet weight (p < 0.01) after radiation therapy. Moreover, both the N-acetylaspartate (NAA) peak and creatine/phosphocreatine (t-Cr) peak were lower after radiation therapy than before. The peaks of both the lipids (Lip) and lactate (Lac) were higher after radiation therapy than before. In conclusion, Cho concentration is thought to be a useful marker for the evaluation of early post-radiation response. The effect of radiation therapy can be evaluated according to the value of Cho. Further long-term MRS study is needed to prove whether or not the decrease of the Cho value in the present study will change before recurrence at later stages.

We report a case of epidermoid, in which proton MR spectroscopy(MRS) provided additional information to MRI. The tumor revealed high signal intensity on T2-weighted images(WI) and low signal intensity on T1 WI. No enhancement was observed. Proton MRS was acquired with the Proton Regional Imaging of Metabolites(PRIME) method(TR/TE/measurements = 2,000 ms/136,272 ms/128 times). Proton MRS revealed lactate(Lac) peak at 1.33 ppm as negative peak at TE 136 ms and positive peak at TE 272 ms. N-acetylaspartate(NAA), creatine/phosphocreatine(Cr) and choline-containing compounds(Cho) were not visible. Lac peak without other peaks such as NAA, Cr, Cho is a unique finding of proton MRS for epidermoid and this could be useful in the differential diagnosis.

A 42-year-old man and a 31-year-old man with congestive heart failure caused by the thyroid stimulating hormone(TSH) secreting pituitary adenoma were reported. Heart failure was improved after transsphenoidal resection of the pituitary adenoma in each patient. The syndrome of inappropriate secretion of TSH causes hyperthyroidism. Thyroid hormone acts directly on cardiac muscle to increase the stroke volume. Hyperthyroidism itself reduces the peripheral vascular resistance and an elevated basal metabolism which is the basic physiologic change in hyperthyroidism dilates small vessels and reduces vascular resistance. The reduced vascular resistance contributes to increase stroke volume. Thyroid hormone also acts directly on the cardiac pacemakers to be apt to cause tachycardiac atrial fibrillation. These mechanical changes in hyperthyroidism increase not only the cardiac output but also the venous return. The increased blood volume and the shortened ventricular filling time due to tachycardia result in congestive heart failure. TSH secreting pituitary adenoma is a rare tumor, however heart failure is common disease. TSH secreting pituitary adenoma should be taken into consideration in patients with heart failure. The presented cases were very enlightening to understand the relation between brain tumor and heart disease.

A 54-year-old woman presented a subarachnoid hemorrhage from a ruptured dissecting aneurysm on the right vertebral artery. A right vertebral angiogram revealed a fusiform dilatation distal to the right posterior inferior cerebellar artery and "pseudo lumen" was observed in a delayed arterial phase. Conservative treatment was carried out, and the patient condition gradually improved. An angiographical examination for planned endovascular treatment 46 days after the onset, revealed the normalization of the formerly dilated caliber of the right vertebral artery with only a minor luminal irregularity. However, 83 days after the onset, right vertebral angiogram showed reappearance of the fusiform dilatation. The right vertebral angiogram obtained 204 days after the onset showed that the dilated segment of the dissecting aneurysm had become normalized to a slight degree. The serial angiographical changes of the dissecting site might have been due to regression and organization following transient thrombosis of intramural hematoma. Such drastic changes within a short period have not been reported yet. In conclusion, careful repeated follow-up is recommended in monitoring aneurysmal formation during the early to chronic phase after rupture of a dissecting aneurysm. The repetition of angiography is important, because later, if angiography has been performed only once, aneurysmal dilatation may be overlooked. One has to be aware of such changes, because such changes may alter the clinician's decision about treatment, as they did in our case.

Some patients with coronary artery disease are diagnosed as having additional carotid artery disease. This subset of patients has been identified as a high-risk group for cardiac and cerebral complications following surgical intervention. Three patients who underwent combined CEA/CABG for coexistent asymptomatic carotid occlusive disease are reported. Case 1: A 69-year-old female who suffered chest pain on exertion. Her coronary angiogram showed severe stenosis of three vessels. Her carotid angiogram showed 98% stenosis of the right internal carotid artery and poor collateral circulation. The severe stenosis of her carotid artery was considered as a risk factor for perioperative cerebral stroke. Intraoperatively, CEA preceded the CABG. Postoperative course was uneventful. Case 2: A 64-year-old male. Intermittent claudication was his initial symptom. His coronary angiogram showed stenosis in three vessels and carotid angiogram showed 75% stenosis in the right carotid artery. Simultaneous CABG and CEA was performed. His postoperative course was uneventful. Case 3: A 62-year-old male whose ECG indicated ischemic heart disease, although he had no symptoms. His coronary angiogram showed stenosis in three vessels, and 80% stenosis of his right carotid artery was observed by carotid angiogram. He underwent simultaneous surgery, and had an uneventful postoperative course. It has been reported that 1.5-8.7% of CABG patients have severe carotid artery stenosis, and perioperative cerebral stroke occurs in 0.9-16%. Simultaneous surgery was successful in our three patients who had asymptomatic carotid artery stenosis. Using this surgical approach for critical coexistent disease may minimize the incidence of perioperative cerebrovascular complications in patients undergoing CABG.

We carried out transthoracic Doppler echocardiography on 38 patients with hypertensive intracerebral hemorrhage(ICH) to examine cardiac functions. The ratio of myocardial hypertrophy and the prevalence of valvular regurgitation were investigated. The E/A ratio which reflects left ventricular diastolic function and the ejection fraction(EF) of each patient were also studied to demonstrate cardiac functions in patients with hypertensive ICH. Myocardial hypertrophy was found in 39.5% of patients with hypertensive ICH. The aortic regurgitation showed a trend to have a higher prevalence in patients with hypertensive ICH when compared to normal volunteer group. Although there was no significant differences in the ejection fraction between groups, the E/A ratio in patients with hypertensive ICH showed a significantly lower value than in normal volunteer group. Therefore, transthoracic Doppler echocardiography demonstrated that patients with intracerebral ICH showed a trend to have a myocardial hypertrophy, aortic valvular regurgitation, and the lower ventricular diastolic function. Thus, transthoracic Doppler echocardiography is useful to evaluate cardiac functions in patients with hypertensive ICH.

Peripherally located aneurysms of the posterior circulation are extremely rare. The outcome of patients with peripherally located aneurysms has been poor, and the treatment of such aneurysms has been surgically challenging. We report a consecutive series of peripherally located ruptured aneurysms in the posterior circulation, and discuss in this article the optimal treatment strategy for such lesions. Clinical presentation, neuroradiological findings, treatment method, and the outcome were reviewed retrospectively. Two cases with distal posterior cerebral artery aneurysm, two with distal posterior inferior cerebellar artery aneurysm, two with anterior inferior cerebellar aneurysm, and one with superior cerebellar artery aneurysm were included in this study (mean age, 59.3 +/- 16.0, M:F = 1:6). Three patients with good neurological status on admission who underwent clipping of the aneurysmal neck via craniotomy showed a favorable outcome. In contrast, four patients with poor neurological status on admission who underwent endovascular proximal occlusion of the parent artery showed an unfavorable outcome. Although the outcome of patients who underwent endovascular surgery was poor, endovascular proximal occlusion was effective in preventing re-rupture of the aneurysms. Proximal occlusion of the parent artery has several shortcomings such as cerebral infarction, but proximal occlusion at the very distal area of the parent arteries would not be critical because of good collateral circulation. Thus, endovascular proximal occlusion may provide us another option in the treatment of peripherally located aneurysms especially in patients with poor neurological status. Further data is needed to discover the optimal treatment for patients with peripherally located cerebral aneurysms.

We carried out transthoracic Doppler echocardiography on 213 patients with ischemic cerebrovascular disease to examine cardiac functions. The prevalence of valvular regurgitation, left ventricular diastolic function (E/A ratio), and ejection fraction (EF) of each patient were studied by transthoracic Doppler echocardiography. In patients with embolic strokes, the prevalence of valvular regurgitation of the left ventricular system such as mitral regurgitation was significantly higher than that of normal controls. In contrast, there was no significant difference in the prevalence of valvular regurgitation in the right ventricular system. Although there was no significant difference in the ejection fraction between groups, the E/A ratio in patients with ischemic cerebrovascular disease showed a significantly lower value than that in normal controls. Patients with ischemic cerebrovascular disease showed a tendency to have an atherosclerotic change in the systemic arteries including cerebral and coronary arteries, reflecting an aggravation of cardiac wall compliance and diastolic dysfunction resulting in lowering of the E/A ratio. Thus, transthoracic Doppler echocardiography was useful to evaluate cardiac diastolic dysfunction and valvular regurgitation in patients with ischemic cerebrovascular disease.

A 54-year-old woman complaining of left hemiplegia was transferred to our hospital. Computed tomography on admission demonstrated normal. Electrocardiogram showed atrial fibrillation. Cerebral blood flow (CBF) was decreased in both the cortex and the perforator territory of the right middle cerebral artery (MCA), whereas the apparent diffusion coefficient (ADC) in the cortex was normal. Digital subtraction angiography (DSA) revealed an occlusion of the right MCA (M 1 proximal) with collateral flow from the right anterior cerebral artery (ACA) to the territory of the right MCA. After intra-arterial injection of tissue-plasminogen activator (t-PA), DSA showed partial recanalization, and the symptoms of the patient improved considerably. Five days after that, the patient deteriorated again and showed disturbance of consciousness and left hemiplegia. In this episode, both CBF and ADC in the cortex of the right MCA were decreased. DSA revealed an occlusion of the right internal carotid artery (ICA) and collateral flow from the right ACA to the territory of the right MCA disappeared. After intra-arterial injection of t-PA, DSA showed partial recanalization with collateral flow from the right ACA, and the symptoms of the patient improved. DSA 5 weeks after onset showed complete recanalization of both the right MCA and the ICA. The patient was diagnosed as both mitral and aortic stenosis and regurgitation (MSR + ASR) and underwent an operation for both mitral and aortic value replacement. She was discharged with no neurological deficit 4 months after onset. ADC analysis is especially useful for the prediction of reversible ischemic damage and the prevention of hemorrhagic transformation and fatal edema in acute ischemic stroke.

Diffusion-weighted magnetic resonance imaging was performed to determine the detectability of ischemic changes in patients with ischemic cerebrovascular disease. We retrospectively reviewed 103 patients with symptoms suggestive of ischemic cerebrovascular disease. All patients underwent computed tomography, routine magnetic resonance imaging, and diffusion-weighted imaging. Of 103 patients, 18 were imaged within 3 hours after onset, 57 were imaged between 3 and 24 hours, and 29 were imaged between 24 and 144 hours. Eighty-eight patients were diagnosed as ischemic cerebrovascular disease. Magnetic resonance imaging was performed at a 1.0 Tesla clinical machine using single-shot spin-echo/echo-planar imaging sequence. In each case, three sets of DWI with motion-probing gradient pulses in the x, y, and z directions were taken. The detectability of ischemic changes of each imaging modality was compared. DWI detected ischemic changes in 83 of 88 cases with clinical diagnoses of cerebral ischemia(sensitivity; 94.3%). In contrast, DWI showed negative findings in 15 of the 15 patients with diagnoses other than cerebral ischemia(selectivity; 100.0%). DWI detected ischemic changes in 16 out of 18 patients(88.6%) within 3 hours after the onset. In contrast, T 2-weighted image did not detect any ischemic changes in the same period. These results suggest that DWI is considered to be highly useful for the early diagnosis of cerebral ischemia.

A 51-year-old male was transferred to our hospital just after traffic accident. On admission, the patient was comatose (Glasgow Coma Scale of 6) and showed a left hemiparesis with a left oculomotor nerve palsy. Computed tomography demonstrated a traumatic subarachnoid hemorrhage without mass lesion. Magnetic resonance imaging showed high intensity lesions on the left dorsolateral midbrain and the right cerebral peduncle. The distribution of lesions implied diffuse axonal injury involving dopaminergic systems such as the substantia nigra and the ventral tegmental area. After several months of conservative management, the patient showed no recovery and was diagnosed as persistent vegetable state. The administration of L-dopa was then started and the patient showed remarkable neurological improvement. Therefore the patient's neurological status was thought to be modified with primary brain stem injury and accompanying traumatic Parkinson's syndrome. It is important to understand "pseudo" persistent vegetative state in the management of patients showing prolonged consciousness disturbance. L-dopa should be considered as the drugs of pharmacological intervention for the patients of masked parkinsonism behind "pseudo" persistent vegetative state whose dopaminergic systems might have been damaged.

We report a case of transient cortical blindness and convulsions during embolization of the cerebellar AVM. A 29-year-old man was admitted to our hospital with subarachnoid hemorrhage. Cerebral angiography showed the right cerebellar AVM fed by the right superior cerebellar artery. Preoperative embolization of the AVM was performed. During embolization, the patient lost consciousness suddenly and appeared to be in a decerebrate posture. About 15 minutes later, the patient came around and complained of total blindness. Cerebral angiography revealed the disappearance of the aneurysm and AVM. There were no abnormal findings in the vertebrobasilar system. Computed tomography obtained just after the procedure, showed considerable contrast enhancement of the occipital lobes. Two hours later, a repeat computed tomography showed clearance of contrast enhancement. Magnetic resonance imaging obtained 12 hours after the procedure, showed no evidence of infarction in the occipital lobes. Two days after, the patient's sight gradually returned. Seven days after the procedure, the patient recovered completely. We speculated that these clinical features might be convulsions due to contrast material. In the reported cases, convulsions and transient cortical blindness due to non-ionic low osmolar contrast materials is a rare complication. This case suggested disruption of the blood-brain barrier demonstrated by the computed tomography appearance of contrast enhancement in the occipital lobes.

We report two cases of refractory pain in a spinal disease. One case was a 60-year-old male who presented intractable pain in bilateral upper extremities after anterior fusion (C5/6, 6/7) for cervical spondylosis. The other was a 63-year-old female who also had intractable pain in the left anterio-lateral chest wall with no remarkable past history. Both cases were refractory to nonsteroidal anti-inflammatory drugs (NSAIDs) or minor tranquilizer or local anesthesia with bupivacaine. However, their pain was significantly relieved by the intravenous administration of a test dose (5mg) of ketamine which is a noncompetitive blocker of N-methyl-D-aspartate (NMDA) receptors. As for case 1, the effect of the injection of the test dose lasted, so continuing infusion therapy of ketamine was cancelled. In case 2, recurrence of the pain was recognized gradually. She underwent continuing infusion therapy of 2mg/kg of ketamine, and it brought about continued pain relief. We conclude that ketamine infusion therapy should also be considered for therapy of refractory neuralgia in spinal disease.

A 65-year-old female was admitted to our hospital with a 6-month history of a gradually enlarging subcutaneous mass in the frontal region. Neurological examination on admission showed no significant abnormality. Skull X-P showed an osteolytic lesion of the frontal bone. External carotid angiogram demonstrated a tumor stain fed by the middle meningeal artery. Computed tomography (CT) showed a slightly high density mass with a marked homogeneous enhancement. MRI revealed an iso-intensity mass on both T1- and T2-weighted images. Gd-DTPA-enhanced T1-weighted images showed a mass with a marked homogeneous enhancement with the "dural tail sign" in the dura adjacent to the tumor. The tumor was totally removed; this mass was diagnosed as a multiple myeloma. No tumor cells were seen in the dura adjacent to the tumor and the mechanism of dural enhancement around the tumor was not clear. However, it is possible that the "dural tail" is due to increased vascular permeability of the dural vessels. Although the "dural tail" sign has been considered as a highly specific feature of meningioma, multiple myeloma can show the same findings on MRI. Therefore, it is important to consider the possibility of multiple myeloma in the differential diagnosis of meningeal tumors.

A 13-year-old girl developed atonic seizure at 2 years of age. At the age of 10 years, gelastic seizures were noted. Magnetic resonance imaging (MRI) revealed a hypothalamic mass protruding down into the basal cistern and up into the third ventricle. An interictal electroencephalogram (EEG) showed paroxysmal spike and wave complex discharges. Since the seizures failed to respond to medical therapy, it was decided to try to control them by removing the mass. The operation was carried out through an interhemispheric trans-lamina terminalis approach. The lesion was so similar to normal brain tissue that the resection had to be limited enough to avoid complications. Histological examination of the mass showed a hamartoma. Postoperative MRI showed residual mass, but no seizure has been noted since the operation. The EEG recorded one year after the operation showed no spike and wave complex discharge, although she was still on anticonvulsant drugs. The authors propose that surgical therapy should be considered as a treatment for intractable gelastic epilepsy with hypothalamic hamartoma and that the first operation should be conservative enough to avoid complications, because it can bring about good results even if it is only a partial resection.

The treatments of putaminal hemorrhages (PH) were evaluated in 14 patients (15 hematomas) with chronic renal failure (CRF). We compared the data of our series with the data of co-operative study (1990) on PH. With regard to consciousness level (Neurological Grading, NG) and hematoma volume, significantly more serious cases were observed in PH with CRF than in PH of the co-operative study. In PH with CRF, mortality (40%) was significantly higher than that in PH of the co-operative study. However, the mortality rate was 0%, 0%, 20%, and 100% in NG1, 2, 3, and over 4b. The mortality rate was 0% in non-surgically treated cases with 0 to 30 ml of hematoma volume, and 0% in surgically treated cases with 10 to 50 ml of hematoma volume. These mortality rates were equal to those of the co-operative study with the same NG, and equal to those of the co-operative study with the same hematoma volume. With respect to functional prognosis, "good" (ADL1 and 2) resulted in 67% of non-surgically treated cases with NG1 to 2, and in 33% of surgically treated cases with NG3 to 4a. "Good" resulted in 33% of non-surgically treated cases with 0 to 30 ml of hematoma volume, and in 40% of surgically treated cases with 10 to 50 ml of hematoma volume. These morbidity rates were equal to those of the co-operative study with the same NG, and equal to those of the co-operative study with the same hematoma volume. Therefore, the high mortality in PH with CRF was suspected to be due to the fact that, in our study, there was a higher distribution of serious cases. These findings indicate that protection against enlargement of hematomas in the acute phase may bring about improvement of prognosis in PH with CRF.

A 26-year-old woman was admitted to our hospital because of headache. CT scan and MRI showed a right subependymal nodule and a left ventricular tumor, neither of which had any enhancement nor were they stained in angiography. Although no skin abnormality was detected, the patient was suspected of tuberous sclerosis. The diagnosis was made because of the subependymal nodule on CT scan and MRI. On June 29, 1995, total removal of a left ventricular tumor was performed by a transcortical approach. Histological sections of this tumor consisted of astrocytic and meningothelial components, containing metaplastic bone formation. Histological diagnosis was dysplastic subependymal tumor. Postoperative course was uneventful. Regrowth of the tumor has not been observed as of now. This case was suspected to involve factors of tuberous sclerosis from a subependymal nodule. However, the ventricular tumor was not diagnosed as a subependymal giant cell astrocytoma.

Three cases of acute subdural hematoma without head injury, but associated with bleeding from cortical artery are described. Case 1: a 74-year-old male had sudden headache during a bronchial asthma attack followed by deterioration of consciousness. He was deeply comatose on admission, and CT scans revealed a huge subdural hematoma. Evacuation of the large hematoma revealed a spurting cortical branch of the middle cerebral artery beneath it. Case 2: Four days before admission, a 69-year-old male developed headache during a fit of coughing. His CT scans on admission showed a thin subdural hematoma. Because it was increasing in volume, the hematoma was removed surgically. A spurting cortical branch of the middle cerebral artery was seen on the surface of the temporal lobe. Case 3: a 80-year-old male, who had had an operation for inguinal hernia under spinal anesthesia ten days before, suffered a sudden headache just after he stood up. CT scans revealed a thick subdural hematoma. As the clot was being removed a spurting artery was seen in the Sylvian region. In a review of 116 surgical cases of acute subdural hematoma at our institute, the incidence of acute spontaneous subdural hemorrhage was 2.6%. The etiology of nontraumatic hematoma is a matter of controversy. Our three cases suggested that the etiology might be the rupture of a cortical artery at the site of adhesion with the dura mater. This would predispose the artery to tearing with minor trauma. Hematoma evacuation by craniotomy and treatment of the ruptured cortical artery were necessary for favorable outcome.

We report unusual radiographic findings which were seen during the management of a patient with anaplastic astrocytoma. An enhanced region in a gyrus of the right frontal lobe was demonstrated in a 38-year-old woman who had had a generalized seizure. Following treatment with steroid- and osmotherapy, this enhanced region decreased clearly on magnetic resonance imaging (MRI). Six months later, an enhancing mass lesion appeared in the same position. After surgery, this was diagnosed as being an anaplastic astrocytoma. It is speculated that the initial enhancement was caused by transient dysfunction of the blood-brain following the seizure. In this case, the most important radiologic image was a T2-weighted image of MRI which was able to demonstrate the existence of the lesion until the time of its removal by surgery.

FLAIR (fluid-attenuated inversion recovery) images are MR images obtained with an inversion recovery sequence having a long inversion time (TI) and a long echo time (TE). We examined 47 cases (56 graphics) of lacunar infarction (LI), 28 cases (32 graphics) of cortical infarction (CI) and 16 cases (23 graphics) of stem infarction (SI) with a FLAIR sequence having a repetitive time (TR) of 6500 msec, a TI of 1700 msec and a TE of 110 msec, and compared these graphics with T2-weighted images by spin-echo sequence (TR 2500 msec, TE 90 msec). LI and CI were better demonstrated with FLAIR images than with conventional T2-weighted images. FLAIR images were very useful in detecting lesions adjacent to the lateral ventricles and the cerebral sulci in particular, because the cerebrospinal fluid signals in the lateral ventricles and the cerebral sulci were low-intensity, with brain tissue appearing as high-intensity areas. In a number of old infarctions, FLAIR images revealed cystic structures, constructed out of internal low-intensity areas and peripheral high-intensity areas. These structural changes suggested that FLAIR images can provide information on pathological changes.

FLAIR (fluid-attenuated inversion recovery) images are MR images obtained with an inversion recovery sequence, which has a long inversion time (TI) and a long echo time (TE). We examined 29 cases (49 graphics) of cerebral contusion, 11 cases (22 graphics) of diffuse axonal injury (DAI) and 11 cases (11 graphics) of traumatic subarachnoid hemorrhage (t-SAH) with FLAIR sequence consisting of a repetitive time (TR) of 6500 msec, TI of 1700 msec and TE of 110 msec, and these graphics were compared with T2-weighted images by spin-echo sequence (TR 2500 msec, TE 90 msec) and computed tomographic (CT) scans. Some lesions of DAI were demonstrated more clearly with FLAIR images than with conventional T2-weighted images. Although contusion could be detected with FLAIR images as well as with conventional T2-weighted images, lesions adjacent to cerebral sulci were better delineated with FLAIR images. Because the cerebrospinal fluid signals in cerebral sulci were low-intensity, FLAIR images were useful in detecting lesions of the cerebral cortex adjacent to cerebral sulci. Although it has been reported that detection of SAH is difficult with standard T1- and T2-weighted images, the presence of t-SAH could be confirmed with FLAIR images as seen in CT scans.

A rare case of simultaneous rupture of multiple aneurysms is reported. A 68-year-old man presented severe headache and vomiting and was transferred to our hospital. CT scan showed subarachnoid hemorrhage (SAH) in the interhemispheric fissure, the right basal cistern, the right sylvian fissure and intracerebral hemorrhage (ICH) in the paraventricle area. Continuation of the hemorrhage could not be detected between SAH and ICH on CT scan. Multiple aneurysms were detected by angiograms on the anterior communicating artery (A-com) and the bifurcation and the distal portion of the left middle cerebral artery (MCA). These findings suggested that SAH was due to a ruptured aneurysm of A-com, and ICH was due to a ruptured aneurysm of the distal portion of MCA. Simultaneous rupture of multiple aneurysms was confirmed by surgical findings. This case indicates that the usual assumption of a single aneurysm rupture in a patient with multiple aneurysms may be erroneous.

We examined the incidence of point mutations in codon 12 and 61 of N-ras gene in human gliomas using PCR with mismatched primers. This method detects point mutations. PCR with mismatched primers induced restriction sites in normal DNA but not in mutational DNA. Genomic DNAs were extracted from paraffin-embedded tissues and were amplified with nested PCR. Among 17 cases, point mutation has not been able to be found so far, when examined in codon 12 of N-ras gene and among 10 cases in codon 61 of N-ras gene. It can thus be said that point mutational activation of N-ras oncogene is an uncommon event in human gliomas.

We have reported the cases of two young patients who presented transient mutism in the course of recovery from removal of a cerebellar medulloblastoma. Although cerebellar symptoms were observed immediately after surgery, neither consciousness disturbance nor sensory aphasia was observed when the patients were mutic. From the analysis of serial magnetic resonance imaging (MRI). Gd-enhanced regions were noticed in the dentate nucleus and the cerebellar peduncle when mutism appeared, and they disappeared when mutism was gone. Although the mechanism of this interesting symptom is not clear, these MRI findings may indicate that focal ischemia or edema associated with surgical procedure may play a role in the appearance of this symptom.

A series of 44 cases is presented of patients who received surgical treatment for unruptured aneurysms in the anterior circulation, and which were associated with ischemic cerebrovascular disease (CVD). The age of patients varied from 34 to 76 (mean 62.8) years old. The associated ischemic CVD was transient ischemic attack (TIA) in ten, minor completed stroke in 23, and major completed stroke in 11 cases. Thirty five patients recovered fully. However, there were three deaths due to new cerebral infarction or delayed intracranial hemorrhage within 30 days after surgery (mortality 6.8%). Transient morbidity occurred in four patients (9.1%), and permanent morbidity in two patients (4.5%). In six cases, new ischemic events occurred after the surgery. In contrast, all 40 patients whose unruptured aneurysms were not associated with CVD fully recovered from the surgery they underwent. The authors indicate three risk factors which might lead to complication; diabetes mellitus, aneurysms located in the middle cerebral artery, and those larger than 6mm in diameter. Another three life-threatening factors are; elderly patients (> 65 year-old), male, aneurysms larger than 7mm in diameter. Direct surgery for unruptured aneurysms in ischemic CVD patients should be considered in cases free of risk factors indicated above. Eight cases in this series had extracranial carotid artery stenosis on the same side as the aneurysm. Carotid endoarterectomy (CEA) was performed prior to aneurysmal clipping in six patients, and their postoperative courses were excellent. In two patients, clipping was performed prior to CEA, and transient morbidity occurred in one of them.(ABSTRACT TRUNCATED AT 250 WORDS)

Subarachnoid hemorrhage (SAH) is commonly caused by ruptured aneurysm or arteriovenous malformation which is detected by cerebral angiogram. However, since angiograms sometimes cannot show the origin of SAH, we review 12 cases (6.3% of total SAH) to assess the management of these cases. We divided the 12 cases into three groups. Group A (occulted aneurysm group) consisted of six cases of which aneurysms were detected by repeated angiographies in four, and by surgical procedures in two. Group U (unknown etiology group) consisted of five cases. Their follow up periods varied from 7 months to 7 years 11 months, and all of them recovered well and had no episode of rebleeding. Group R (rebleeding group) consisted of one case which fatally re-bled on the second day. Group A tended to be Hunt and Hess grade 3, and Fisher group 3 or 4. In contrast, group U tended to be H and H grade 1 or 2, and Fisher group 2. However by their clinical and neuroradiological findings alone, it was not possible to distinguish the two groups certainly. This means that the patients whose initial angiography does not show the origin of bleeding must be cared for as an occult aneurysm case. Twice repeated angiograms should be programmed. In our cases the first was carried out on the seventh day in the hope that the reason for vasospasm of the parent artery might be shown to be a hidden aneurysm. The second was carried out sometime between the 14th and 21st day because of thrombolysis in the aneurysm, and because it was necessary to relieve vasospasm.(ABSTRACT TRUNCATED AT 250 WORDS)

To assess the efficacy of magnetic resonance (MR) imaging for detection of associated brain injuries in cases with extradural hematoma (EDH), 32 patients of EDH were examined by MR. CT detected associated lesion in eleven patients (34%), while MR detected them in 24 patients (75%). MR is more sensitive than CT in detecting associated lesions, especially when T2 weighted imaging is used. Non-hemorrhagic contusions adjacent to EDH, and near the cranial base were well shown by MR, however they tended to be missed by CT. EEG findings were clearly related to abnormalities detected by MR. Coupling between functional change and organic change was confirmed. The improved detection and anatomic localization of associated brain injuries by MR should allow more accurate assessment of brain injuries, and sophisticated management of EDH patient. The authors also discussed on the cardiorespiratory monitoring and support during MRI examination in critically ill patients.

It is considered that cell adhesion molecules play important roles in the host-graft interaction during the reconstruction of the injured nervous system by neural transplantation. In this article, we report the expression of such molecules during the migration and differentiation of donor Purkinje cells in the adult rat cerebellum. Cerebellar primordium at the 14th day of gestation was transplanted into the adult rat cerebellum. Purkinje cells which had migrated from the grafted tissue into the host molecular layer were identified immunohistochemically with anti-spot 35 antibody, a specific marker for Purkinje cells in the cerebellum, as well as by labeling them with bromodeoxyuridine at their final mitotic period. In the grafted site, transient expression of a neuron-glia cell adhesion molecule, tenascin, was detected immunohistochemically. This molecule was expressed in the host tissue adjacent to the migratory Purkinje cells as well as within the donor immature tissue. Tenascin was not detected in the host tissue far distant from the grafted tissue. In considering the expression of tenascin in the migratory process of Purkinje cells during cerebellar development, this molecule induced in the host tissue may be involved in the migration of donor Purkinje cells.

A case of asymptomatic Dandy-Walker syndrome (DWS) complicated by cerebellar hemorrhage is reported. A 65 year-old man was hospitalized for investigation and treatment of disturbance of consciousness. CT scan and MRI showed a large hematoma in the posterior fossa cyst. Postoperative CT scan and MRI revealed the DWS and cerebellar hemorrhage on the left side. This patient had no symptom until 65 years of age, in spite of having DWS. There has been no such case reported in the literature to our knowledge. Derangement of secretion and absorption of cerebrospinal fluid seem to have been the cause of late-onset symptoms after a long well balanced symptom-free period.

To assess the efficacy of surgical resection of brain metastases from patients with multiple brain metastases or/and with other systemic metastases, the authors analysed treatment results of 90 cases of metastatic brain tumors. The patients were divided into three groups. Group A (nine cases): Patients with single brain tumor and their primary cancers were well controlled. Their brain tumors were removed surgically and followed by radiation. Their mean survival time was 17.0 months, and 14.6 months were independent (Karnofsky score greater than or equal to 70) in cases of lung cancer. Five patients (55.6%) improved by treatment. Group B (21 cases): Patients with multiple brain metastases or/and with systemic metastases. Their brain tumor(s) which gave rise to neurological symptoms were surgically removed in order to improve their quality of life. In cases of lung cancer, mean survival time was 9.5 months and 7.1 months were independent. 11 patients (52.3%) improved by treatment. Group C (60 cases): Patients treated conservatively. Their mean survival time was 4.9 months and 2.7 months were independent in cases of lung cancer. Only 13 patients (21.7%) improved by treatment. However 23 (38.3%) deteriorated in their quality of life during treatment. Two patients of this group had single brain tumor and their primary cancers were controlled well. They refused surgery. Their mean survival time was 13.0 months, and 7.0 months were independent. These times were statistically shorter than group A. Seven patients had similar systemic and neurological states as those in group B. Their mean survival time was 5.0 months and 3.0 months were independent. These times were also statistically shorter than those in group B.(ABSTRACT TRUNCATED AT 250 WORDS)

We studied 828 cases with occlusive cerebrovascular disease who were admitted to our hospital over these 5 years in relation to surgical management. Cerebral angiography including digital subtraction angiography was carried out in 770 cases. Surgical management was carried out in 110 cases; 77 cases of carotid endarterectomy (CEA), 18 cases of EC-IC bypass and 15 cases of external decompression. The ratio of surgical management was 13. 3% of all cases admitted. The mortality and the morbidity were 5.4% and 1.8% respectively. The number of EC-IC bypass has decreased gradually after the reports of international cooperative study concerning with EC-IC bypass in 1985. But the number of CEA has increased gradually.

Hematomas of the basal ganglia in head injury have long been recognized by pathologists with an interest in head injury but their mechanism has not been revealed clearly. We report two cases of bilateral traumatic hemorrhage in the basal ganglia. Case #1, a 17-year-old male was admitted to our hospital immediately after a traffic accident. Neurological examination revealed that the patient was comatose and had right hemiparesis. CT scan showed bilateral hemorrhage of the basal ganglia and subarachnoid hemorrhage in the perimesencephalic cistern. MRI showed high signal intensity areas in the bilateral basal ganglia, perimesencephalic cistern, cerebral white matter and corpus callosum. The patient was diagnosed as having diffuse axonal injury coinciding with bilateral hemorrhage of the basal ganglia. Stereotactic aspiration for the hematoma of the left basal ganglia was carried out. Case #2, a 75-year-old male was admitted immediately after falling from the roof of his house. Neurological examination revealed no neurological deficit except for headache and nausea. CT scan on the day of injury revealed no abnormality. But CT scan 12 hours following the injury showed bilateral hemorrhage of the basal ganglia. Blood pressure of the patient was within normal range and he was diagnosed as having traumatic bilateral intracerebral hematoma. Conservative treatment was carried out and the patient was discharged 7 days after injury with no neurological deficit. The mechanism of traumatic hemorrhage of the basal ganglia has not been clear. In case #1, diffuse axonal injury (DAI) may have played an important role in the bilateral hemorrhage. But in case #2, non-DAI factor such as vasoparalysis syndrome may have existed.(ABSTRACT TRUNCATED AT 250 WORDS)

In this study we quantified the morphological abnormalities of human glioma vasculature in operated sample of low grade astrocytomas and malignant gliomas. Only those vessels with a diameter of less than 10 micron and containing one nucleus at least on axial section present in the marginal area of the tumors devoid of necrosis were subjected to the present study. A total of 58 vessels were analyzed with computer assisted morphometry for ultrastructural evidence of proliferative potentials of endothelial cells. 5 specific features of the endothelial cells and/or the capillaries which were not related to the vascular permeability were assessed: (1) Degree of vascular luminal narrowing (LN: Ratio of luminal area to abluminal area), (2) Thickness of basement membrane (BM), (3) Mean % ratio of the endothelial cells including Weibel-Palade bodies to whole endothelial cells (WPB-1) and the number of Weibel-Palade bodies in an endothelial cell section (WPB-2), (4) Irregularity of nuclear shape (NA: semiquantified grade 0 to 3). (5) Mitochondrial density (MIT). We found that: (1) LN was significantly stronger in malignant glioma capillaries (MGC, 28%) than low grade astrocytoma capillaries (LAC, 39%). (2) BM was significantly thicker in MGC (2.9 microns) than in LAC (1.2 microns), (3) WPB-1 and WPB-2 were significantly higher in MGC (34% and 0.92) than LAC (14% and 0.39). (4) NA was significantly higher in MGC (grade 2.1) than LAC (grade 1.3), (5) MIT was significantly higher in MGC (5.6%) than LAC (4.2%).(ABSTRACT TRUNCATED AT 250 WORDS)

In this study we investigated the ultrastructure of human glioma capillaries in operated sample of low grade astrocytomas and malignant gliomas. Electronmicrographs of a total of 58 vessels were analyzed with computer assisted morphometry for ultrastructural evidence of permeability routes. All of these vessels were present in the marginal area of tumors devoid of necrosis, less than 10 micron in diameter and containing one nucleus at least on axial section. We found that: (1) The number of pinocytic vesicles was significantly higher in capillaries from malignant glioma (an average of 8.1 per 1 micron (2) cytoplasm) than those from low grade astrocytoma (an average of 4.0 per 1 micron (2) cytoplasm). In capillaries from malignant glioma, most of the pinocytic vesicles were arranged in the abluminal side of endothelium and some of them were fused each other. (2) Abnormal endothelial intercellular junctions which were defined as short tight junctions (less than or equal to 0.25 microns) were equally but infrequently seen in low grade astrocytomas and malignant gliomas. (3) Fenestrations in the endothelium were not seen. Therefore we suggest that the high vascular permeability and resultant brain edema in malignant gliomas is likely to increased pinocytic vesicles and rare but abnormal inter endothelial junctions.

Spinal instrumentation surgery has come into wide use recently, especially for tumor of the spine. It is very effective for fixing the spine for relieving the patient from pain. But the decision about the indication of instrumentation surgery for tumor of the spine must be made carefully. In cases of double malignant tumors including spinal tumor, it is hard to decide how to treat tumor of the spine. We report a case of 78-year-old male with multiple myeloma of the cervical spine and cancer of the prostate. The patient had been in good health until one year previously, when he started to complain of nuchal pain. He became bedridden with loss of voluntary control of the right upper extremity for the last two months. Then he was admitted to our hospital and radiological examination was carried out. It revealed tumor of the cervical spine and it seemed to be bone metastasis. Further examination revealed that the patient was suffering from multiple myeloma and cancer of the prostate. The tumor of the spine was diagnosed as either multiple myeloma or metastasis of cancer of the prostate. Spinal instrumentation surgery using Luque-rod was carried out as one of the comprehensive treatment plans for double malignant tumors. The instrumentation surgery was effective for fixing the spine and improving the patient's quality of life. In operative procedures, intraoperative spinal cord monitoring was carried out. Intraoperative spinal cord monitoring was indispensable for preventing spinal cord injury. The tumor of the spine was diagnosed as multiple myeloma by pathological examination.(ABSTRACT TRUNCATED AT 250 WORDS)

Stereotactic aspiration for intracerebral hematoma has become widely used due to improvements in computed tomography (CT). CT-guided stereotactic aspiration for hypertensive intracranial hematomas was performed in 46 cases. Stereotactic aspiration with coordinate software was carried out among 16 cases. We compared the clinical results of conventional stereotactic aspiration with results of the new method using coordinate software. Using coordinate software, we can examine the route for the target point, as well as the target point of the hematoma before surgery. Therefore we can avoid obstacles such as ventricles and internal capsules. Further, we can aspirate hematoma by using only this one procedure. Mean hematoma aspiration percentage has risen from 44.9 to 87.2% by using coordinate software. Rate of drainage tube insertion after operation has decreased from 90 to 50%. The period of placement of the drainage tube and the frequency of infection due to the drainage tube has become lower, too. Therefore we can say that the outcome of treatment of hypertensive intracranial hematomas is improved by using coordinate software.

A nine year old boy with sudden onset of loss of consciousness was brought to the emergency room where he was in deep coma with bilateral decerebrated rigidity, and fixed dilated pupils. Computerized tomographic scan showed an intracerebral hematoma in the left temporal lobe associated with signs of uncal herniation. He was taken to the operating room immediately and craniotomy was started. After aspirating a small amount of hematoma through a burr hole, left carotid angiography was carried out by using a portable digital subtraction angiography (DSA) unit. The procedure took approximately ten minutes, and it showed arteriovenous malformation (AVM) supplied by a temporal branch of the middle cerebral artery. Using this angiogram as a guide, the intracerebral hematoma and the AVM were completely removed. The patient recovered well and returned to school after rehabilitation. This case illustrates a method of treatment for intracerebral hematoma with impending herniation. Although, in general, preoperative angiography is required before the operation of AVM, it could be argued that time spent for angiography may result in irreversible damage to the brain stem in the presence of uncal herniation. We chose to perform intraoperative portable DSA during evacuation of the hematoma instead of wasting time on preoperative angiography. With this method, we were not only able to remove the hematoma without delay, but were also able to extirpate the AVM safely. Whether or not our method can be used in general remains to be seen, and further experience is required.

A typical case of spontaneous spinal epidural hematoma was reported. The patient was a 52 year-old male. He suddenly developed severe high back pain followed by complete paraplegia and rectovesical insufficiency. Myelography disclosed epidural mass extending fro Th2 t0 Th4. Laminectomy and removal of hematoma were carried out 4 days after the onset. Post-operative course was uneventful. Four months later he began to walk with the aids and 7 months later he was fully ambulatory and discharged. We analysed 110 cases already reported including our own and obtained the following conclusions. Spontaneous spinal epidural hematoma was 67% and secondary one 33%. The most frequent precipitating factor was usage of anticoagulant followed by trauma and vascular anomaly. There were relatively many case below the age of 15. The level of lesion predominated in thoracic region. Early operation was imperative but even in delayed cases good result could be expected especially in younger patient and those with lumbal lesion.

We report two cases of traumatic cerebral vascular disease which were treated successfully with barbiturate. The first case sustained blunt trauma to the bilateral vertebral arteries, resulting in complete occlusion of both arteries. After ligation of the injured vertebral arteries, multiple cerebral infarction appeared. Cerebral angiography revealed dissection and stenosis of the bilateral internal carotid arteries. We treated this case with barbiturate (Thiamylal) in combination with administration of heparin. The second case sustained cerebral contusion and traumatic subarachnoidal hemorrhage as a result of a motor cycle accident. This patient deteriorated and cerebral angiography showed diffuse cerebral arterial vasospasms. When this was treated with induced hypertension, he developed recurrent subarachnoid hemorrhage. In order to protect the brain from ischemia without elevating blood pressure, we employed barbiturate therapy and the patient recovered without major neurological deficit. The condition of severe head injury with cerebral ischemia is complicated. Therefore it has been hard for neurosurgeons to cure the patient with this condition. But we treated it with barbiturate successfully. Barbiturate therapy in severe head injury with cerebral ischemia may decrease the mortality in that group of patients considered difficult to treat with the usual therapeutic modalities.

Recently much attention has been paid once again to etiology of chronic subdural hematoma since the appearance of computed tomography (CT). Authors examined 1824 head injury cases by CT from January 1977 to September 1979. Among them, there are 40 cases (they were all over 16 years old) whose CT showed frontal extracerebral low density area. The low density area which is considered to be so-called fluid collection could be classified into four types (type I to IV). In two cases of those 40 cases (5%), the low density area changed into high density area which seemed to be hemorrhage. The 2 cases were diagnosed to be chronic subdural hematoma and proved surgery. The change of density on CT developed only from type I (the brain surface looks smooth and sulci are not recognized beneath the low density area). The change of density, occurred in 2 cases among 24 cases of type I (8.3%), was recognized about 2 months after the head injury. This fact is compatible with the report by Yamada et al. (1979). Thus, when CT after the head injury shows frontal extracerebral low density area of type I, the case may develop to chronic subdural hematoma about 2 months after the head injury. Therefore, careful observation should be needed especially during this period after the head injury.

The authors report a case of spontaneous occlusion of an arteriovenous malformation (AVM) verified by the second angiography performed 3 days after the initial one. This 65-year-old man had a sudden attack of headache, nausea, and vomiting and was admitted to our hospital next day. On admission, CT scan showed subcortical hemorrhage in the right temporo-parietal area and right CAG showed a small AVM in the same area. The main feeder was a MCA distal branch and the drainer joined Labbe's vein. Repeated angiography 3 days after initial one failed to demonstrate the AVM. Craniotomy was performed and thrombosed AVM was totally removed. Mechanism for disappearance of the malformation is assumed to be acute thrombosis due to intracranial hemorrhage and arteriosclerotic change. The literature is reviewed.

A rare case of a spinal epidural AVM fed by bilateral internal iliac arteries is reported. The patient was a 50 years old female with symptoms of slowly progressive paraparesis and sensory disturbance below L-2 associated with sphincter disorders. Myelography disclosed a serpiginous filling defect at the lumbar region. Selective internal iliac arteriograms disclosed an AVM fed by bilateral lateral sacral arteries. The nidus was excised totally, then a gradual improvement of those symptoms followed. Reviewing the literature, only 9 cases of spinal AVM of this type have been reported. In the majority of these cases, symptoms progressed slowly from the lower sacral level up to a level close to the end of the drainer. These symptoms were considered to be caused by steal phenomenon as well as by venous congestion due to arterialized intradural draining veins.

The diagnostic value of brain scintigraphy in intracranial diseases has been well recognized. Numerous reports have appeared in the literature concerning its use in adult cases. The reports dealing with pediatrics cases, however, are quite limited in number. The major factors limiting such studies in children may be considered as follows; (1) infratentorial tumors are common in this age group, in which its diagnostic accuracy has been believed to be quite low, (2) problems of exlosing children to radiation and (3) difficulty in keeping children in one position for a considerable length of time. These difficulties were almost overcome by the use of 99m Tc with a very short half life and a gamma camera, resulting in increased application of this procedure to children. The purpose of this report is to analyse and discuss the scintigraphical characteristics in children and evaluate the diagnostic value in brain tumors. The subjects consist of 199 non-tumoral cases and 53 cases of verified brain tumors. Following conclusions were obtained: (1) Aging changes are noted in normal brain scintigrams of children. One of them is related to the mode of visualization of the basal structures in lateral views. The cranial base appears to be flat before the age of 4 years. A triangular process then appears at the cranial base, approaching that of adult over the age of 10 years. Another change is related to appearance of the temporal and occipital muscles over the cranial vault and the posterior fossa. This becomes apparent about the age of 7 years and produces such masking effects as to interfere with diagnosis in this region over the age of 10 years. (2) The choroid plexus are visualized in about 10% of cases. (3) In brain tumor cases, the detecting rate is 93% in gliomas, and 73% in non-gliomatous tumors. It is particularly low in congenital tumors.

Fourteen cases of cerebellar hemorrhage were analysed from the point of CT-scan, and the following results were obtained. 1. The number of cases of cerebellar hemorrhage forms 4.4% of that of total intracranial hemorrhage. 2. Most of the cerebellar hematomas extend upward. Downward extension is rare. 3. In acute dead cases hematomas are 5 cm or more in diameter and lie over bilateral hemistpheres with the extension to third or fourth ventricles in CT-scans. 4. Slowly progressive cases are deteriorated by the secondary hydrocephalus. 5. In mild cases hematomas are 3cm or less in diameter on CT-scans and the hematoma evacuation is not indicated for these cases. 6. The shunt operation alone is sufficient for the life saving of the slowly progressive cases, but the hematoma evacuation is indicated in these cases if the functional prognosis is taken into consideration. 7. Immediate hematoma evacuation together with the ventricular drainage is considered to be effective for the life saving of the acute fulminant cases.

The computed tomogrpahy has been proved to be highly reliable in diagnosis of CNS diseases. The findings in 26 cases of metastatic brain tumors, and 2 cases of meningeal carcinomatosis performed with Hitachi CT-H scanner are analized. Metastatic tumors are seen on plain CT as mainly isodense nodules (60%). But, on enhanced CT, they increase in their density (97%). Larger nodules of metastatic tumors (over 2 cm in diameter) are tend to contain less dense central area, so called central cavitation. The direction of the expansion and/or extension of the perifocal low density is characteristic to the location of the tumor. In cases of meningeal carcinomatosis, diffuse periventricular higher density can be recognized enhanced CT.