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Large skull base meningiomas frequently encase the major cerebral vessels and cranial nerves, and receive blood supply from the branches of the internal carotid artery. One-stage resection of these tumors is difficult due to the long time needed for surgery and profuse bleeding from the tumor. We report herein a case of large sphenoid ridge atypical meningioma that was successfully resected using a combination of two-stage surgery and irradiation. A 56-year-old man was referred to us with mild left hemiparesis and visual deterioration. Computed tomography and magnetic resonance imaging showed a large sphenoid ridge meningioma. Angiography showed blood supply from the branches of both external and internal carotid arteries, and pial blood supply from the middle cerebral artery. In the first surgery after embolization of feeder vessels from the external carotid artery, the tumor was still hemorrhagic and was partially resected with 2,374 ml of blood loss. Symptoms were improved after the first surgery. Pathological diagnosis was atypical meningioma. In the second surgery after 40 Gy of irradiation, the remnant tumor was no longer hemorrhagic and was totally resected. Staged surgery with irradiation is one treatment option for large vascular skull base meningiomas, particularly for atypical meningiomas.

We retrospectively studied subarachnoid hemorrhage (SAH) patients with delayed ischemic neurological deficit (DIND), and analyzed the factors causing extremely late onset of deficits occurring over 15 days after onset of the SAH. Among 605 patients with SAH, 201 (33%) developed DIND. Among DIND patients, 137 had undergone early aneurysm surgery. In these 137 patients, onset date of DIND was definite in 131 patients. Six patients (5%) developed DIND over 15 days after SAH. All 6 had asymptomatic angiographical vasospasm and infections, most often meningitis, before the onset of DIND. Compared with cases in which there was ordinary onset of DIND, other statistically significant factors among these 6 patients were intracerebral hemorrhage, sepsis and meningitis. We suspect that DIND were manifested subclinically in the early period because of the associated hyperdynamic hemodynamics resulting from sepsis in these patients.

Thirty one cases of prenatally diagnosed CSN malformations were encountered in our institutions between 1982 and 1988. There were 42 disclosed lesions including 24 hydrocephalus, 3 anencephaly, 3 myeloschisis, 3 holoprosencephaly, 3 encephalocele, 2 Dandy-Walker cyst, 1 hydroencephalodysplasia, 1 brain tumor (Teratoma), 1 sacrococcygeal teratoma and 1 sacral agenesis. The gestational age at diagnosis ranged from 24 to 40 weeks of gestation (average 33.4 weeks). All were diagnosed by ultrasonography, and either MRI or whole body CT was additionally performed to evaluate the morphology in ten patients. MRI was a definitely useful diagnostic tool to evaluate the intracranial morphology, whereas whole body CT was much superior to other diagnostic imagings to visualize the condition of cranium or cranial sutures. Using these diagnostic procedures the type of hydrocephalus, was able to be identified, according to the major categories, in the individual cases. Spine morphology, however, was not detected n such high quality by MRI. Ultrasonography combined with application of whole body CT, with or without MRI, may be the best method now available to diagnose spina bifida. However, at the present time, this cannot be done until after 24 weeks of gestational age. It is our strong impression that such diagnostic technique for fetal CNS malformations will be improved, and selection of therapeutic modalities will be decided in the prenatal period before birth in the near future. It will be a dramatic change in the clinical historical phase in the treatment of CNS malformations, but establishment of therapeutic regimen along with more precise analysis of natural history, pathophysiology, postnatal outcome and ethical aspects of these congenital anomalies is required.

Results of Computerized Axial Tomography with and without intravenous contrast (60% Conray) in 24 patients with multiple brain tumors were analyzed. Of the 24 patients, 19 had metastatic brain tumors, 4 multiple gliomas and 1 patient had multiple meningiomas. Data obtained by C.T. scan were compared to results obtained by angiography and nuclear scanning. In the diagnosis of multiple metastatic brain tumors. C.T. scans were superior to the other two procedures. however, C.T. scanning detected 4 lesions in the case of multiple meningiomas, while angiography disclosed 11 tumors in the same patient. In one patient having multiple gliomas, one (vascular) lesion only was demonstrated by angiography. Many other evaluations of Computerized Axial Tomography have been reported and the advent of this unique non-invasive radiologic technique has resulted in marked changes in the neuro-radiological diagnostic approach to brain tumors. However, it is important to recognize the weak as well as the strong points of each diagnostic procedure including the C.T. scan. At present, in our opinion, even with a positive demonstration of a brain tumor by C.T.scanning, cerebal angiography should be carried out prior to surgical intervention.

Metastatic carcinoma was found in 9 pituitary glands (24%) of 37 patients undergoing transphenoidal hypophysectomy for diffuselly metastatic breast carcinoma. In all cases the preoperative neurological examination was negative, as were neuroradiological studies, including skull X-ray, tomograms of the sells turcicabrain scan, and angiography. Diabetes insipidus, however, was seen more frequently in patients with pituitary metastasis preoperatively (3 of 9) and postoperatively (8 of 9). Four of the nine patients with pituitary metastasis developed severe diabetes insipidus, which continued more than one month, while similar severe disease was seen in three of twenty-seven cases with no pathological evidence of pituitary metastasis. The prognosis in patients with pituitary metastasis was poor, with seven of the nine dying with an average survival of eighteen months. Pathological studies disclosed metastatic lesions in the anterior lobe (78%), posterior lobe (44%), and stalk (11%). The study emphasized that pituitary metastases, usually considered to be rare, occurred in 24% of patients with diffusely metastatic breast carcinoma. Such metastases correlate with the development of severe diabetes insipidus and with poor prognosis.

The warning signs of rebleeding in the ruptured cerebral aneurysms, and the effect of antifibrinolytic treatment on the prevention of rebleeding from the ruptured aneurysms were studied and evaluated satistically by analysing the 62 single ruptured aneurysms. The incidennce of rebleeding during waiting time for surgery was higher in the following factors, i.e., the older patients, the Grade 2, the higher blood pressure, the larger aneurysms, the anterior-communicating aneurysms, the vasospasm. The critical time for rerupture was within three days after admission and within seven days after last bleeding. The anti-edema treatment and the sedation treatment have no effect upon the rebleeding. There was no difference in incidence of rebleeding among the sex and the frequency of bleeding before admission. The operative mortality of the reruptured patients during waiting time for surgery was very high. The antifibrinolytic treatment definitely lessened the incidence of rebleeding of the ruptured aneurysms during waiting time for surgery, and there were no noticeable complications following this treatment. This treatment is of value in the prevention of rebleeding from ruptured cerebral aneurysms during waiting time for surgery.

We have experienced with 50 cases of parasellar tumors, four cases of which had persistent thirst, polydipsia, polyuria, and reversible temporary hyponatremia secondary to hypernatriuresis. The mechanism of the syndrome in these four cases could not be explained by either that of the syndrome of hypernatremia or of the so-called SIADH. We tentatively named this syndrome as "CEREBRAL POLYURIC HYPONATREMIA" and the criteria of this syndrome as as follows: 1) persistent thirst, polydipsia polyuria, 2) reversible temporary hyponatremia secondary to hypernatriuresis, 3) exception of the following items--administration of uretic drugs, renal and adrenal dysfunction, hyperglycemia, hyperlipemia, overadministration of water, and poor administration of NaCl. The mechanism of this syndrome is presumed as follows: 1) compression by a tumor or surgical attack to the anterior hypothalamus, 2) disturbance of the mechanism of ADH secret-on, 3) extrasecretion of natriuretic factor possibly produced in the anterior hypthalamus, and 4) preservation of the thirst center.

The radical operative procedure for premature closure of metopic suture (trigonocephaly) was theoretically discussed on the basis of the pathophysiological concepts analyzed by the CT measurement. The authors experienced with 7 cases of trigonocephaly of infancy during the last 3 years. CT measurement for the analysis of development of the anterior cranial fossa/the orbital roof, was made on these cases setting up the standard of nasiopterional angle (N-P angle), nasio-clinoid angle (N-C angle), bi-pterional distance (B-P distance) and nasio-clinoid distance (N-C distance). Random sampling was done for the normal value or control from 30 normal childrens' CTs. The results revealed the fact that trigonocephaly in infancy has more markedly acute in N-P angle and short in B-P distance for more severely deformed trigonocephaly, but was within normal limit in N-C distance with normally shaped fronto-nasal angle. The theoretical operative goal for the early radical reconstructive procedure in trigonocephaly was felt that the lateral and superior orbital burrs should be advanced with the nasion as the key point until obtaining normal N-P angle and B-P distance. By performing the above procedure with tight fixation of 1 cm square bone fragment on each side, a satisfactory expansion of the anterior cranial fossa could be obtained as a result. The prematurely closed metopic suture should be stripped off down to the nasion to correct hypotelorism.(ABSTRACT TRUNCATED AT 250 WORDS)

Ependymomas constitute 6.1 to 12.7 percent of pediatric intracranial neoplasms with a predominance of male patients, younger children and infratentorial involvement. Although there is a generally accepted pathological classification of ependymoma, the prognosis and surgical results of this tumor do not always correlate with the apparent tumor malignancy. We analyzed 38 ependymomas in children in light of the prognosis and its affecting factors. Thirty-three were intracranial and 5 were intraspinal. Among 33 intracranial ependymomas, 20 were infratentorial (4th ventricle) 9 were in the lateral ventricle or cerebral parenchyma and 4 were in the para third ventricular region. In age distribution, 3rd or 4th ventricular ependymomas were seen in younger children, under the age of 10 years, except for one child; while ependymomas in the lateral ventricle, cerebral parenchyma or spinal cord were more common in older children. Malignant ependymomas or ependymoblastomas were found in 14 intracranial ependymomas involving equally each location. The surgical mortality in 38 ependymomas was 0. The five year survival rates in malignat ependymomas and low grade ependymomas were not significantly different. However, the five year survivals in the 3rd or 4th ventricular ependymomas were extremely poor, 20% and 0% respectively, while lateral ventricular or intraparenchymal ependymomas had an excellent survival rate of 60% at five years. The patients with total tumor removal survived significantly longer (5 year survival 50%) than with subtotal resection (5 year survival 25.5%) or biopsy (5 year survival 16.6%). All patients except 4 were treated with radiation therapy. The clinical significance of radiation therapy will also be further discussed.

Fifty-nine pituitary adenomas treated with transsphenoidal approach were analyzed in the light of visual field defects and the postoperative cure rates. Twenty-six cases had visual field defects. The majority of the defects were temporal 1/2 or superior 1/4, although atypical deficits such as incongruous homonymous hemianopsia, nasal 1/2 defect, superior 1/2 defect, peripheral constrict were seen. The visual field defects were correlated with the size of the tumor in Hardy and Vezina classification of the suprasellar extension. The visual field defects appeared in 100% of Type C, 89% of Type B, 50% of Type A, 0% of Type O. In 24 out of 26 patients with preoperative visual field defect, the visual field improved either to normal or wider fields postoperatively. There were 9 patients with optic atrophy, which also showed the correlation with the tumor size. Only the tumor of Type B or C revealed optic atrophy but still 45.4% patients in this group had no optic atrophy. The visual field defect in 85% of the patients without optic atrophy improved to normal post-operatively, while 66% with mild and only 20% with severe optic atrophy showed complete recovery. In conclusions, authors emphasize followings. 1) Improvement rate in the visual field defect of pituitary adenomas by transsphenoidal approach was superior to the previously reported rates by transcranial operations. 2) The factors affecting the functional prognosis in the visual field defect are the natures of the tumor, surgical approach and the factors affecting the plasticity of the optic nerves. The existence and degree of optic atrophy could be one of the references for the plasticity of the optic nerves. 3) There is a close relation between the morphological potential of the tumor and optic atrophy/visual field defect. From these standpoints of view, the early diagnosis and treatment should be emphasized.

Clinical aspects with disturbances in fluid and electrolytes metabolism in brain diseases were discussed reviewing 41 cases experienced in our department. These 41 cases were found in 377 patients with diseases of the central nervous system in our hospital during recent 14 months. Hyponatremia was found in 19 cases and aneurysms of A-C, A1 and A2 had the majority of the cases. The cerebral angiography suggested an unstable blood supply to the anterior portion of the hypothalamus, for instance, showing remarkable shift, spasm or obstruction A-C, A1 or A2. The duration of hyponatremia was transient and mostly less than 2 weeks after the last attack of subarachnoid hemorrhage. On the contrary, hypernatremia was seen in 9 cases and 6 of them were found in cases of tumors in the pineal region and A-C, A1 and A2 were intact angiographically. The hypernatremia was continuous and did not response to V-P shunt or any kinds of infusion therapy. The hypernatremia due to cerebral disease is thought to be a result of destruction of the supraoptic and paraventricular nuclei or adjacent area in the anterior potion of the hypothalamus in most of presumed these cases. It might be that the decreased blood supply to the anterior position of the hypothalamus offers an information not of hypoosmolarity but of hypovolemic state, and this information increases the secretion of ADH. This mechanism of hyponatremia could play an important role in S.I.A.D.H.

Cerebrovascular disorders in children is a rare clinical entity, epidemiologic studies of which are very scarce in Japan. Hence this study analyzed 13,131 sick children admitted to Children's General Hospital in light of the incidence of cerebrovascular accident in children and its specific characteristics. In this paper, the cases of cerebral infarct are analyzed with special reference to their developmental outcomes. The results show that one hundred twenty children (0.85 percent of all sick children) had cerebrovascular disorders documented both in clinical pictures and CT scans. This number accounted for 2.5% of 4,738 CT examinations performed for these sick children. There were 79 cases of intracranial hemorrhage, 24 of cerebral infarction and 17 of vascular anomalies, 65.8%, 20.0% and 14.2% respectively. In the intracranial hemorrhage group, there was a different pathophysiology in each age group. The fact that intraventricular hemorrhage occurred in premature neonates, subarachnoid or posterior fossa subdural hemorrhage in mature neonates and infants, and intracerebral hematoma in elder children due to different causes was very striking. In the cerebral infarct group, the middle cerebral artery was most commonly affected (11 out of 24 cases); others had various lesions such as lacunar stroke, internal carotid artery occlusion and so on. The most impressive but disappointing fact in those children was that their clinical pictures were quite miserable, revealing low IQs. Nine out of 24 children with cerebral infarct had IQs below 20. In the abnormal vessels group, there were Moyamoya disease, arteriovenous malformation, intracranial aneurysm, Sturge-Weber syndrome, Menkes disease and coiling of the internal carotid or vertebral arteries each demonstrating unique angiographic findings.(ABSTRACT TRUNCATED AT 250 WORDS)

Twelve cases of G.I. tract bleeding, treated in the Department of Neurosurgery, Kobe University School of Medicine, were analyzed with the special reference to clinical data before the episode of G.I. tract bleeding. These 12 cases consist of 10 cases of aneurysm, 1 of metastatic brain tumor, and 1 of chronic subdural hematoma. The anterior communicating artery has the majority in the case of aneurysm by 50 per cent. In each case, C.B.C., bleeding time, coagulation time, serum electrolytes, serum glucose, glucosuria, steroid administration, blood pressure, hyperthermia, and water balance were reviewed retrospectively. Only serum glucose showed the specific abnormality with the average of 135 mg/dl (Hoffman method) before the episode of G.I. tract bleeding among them. In 1931, Cushing reported the clinical case of G.I. tract bleeding with intracranial disease and also experimental G.I. tract bleeding, in which discussion he concluded only parasympathetic nerve system has the involvement in the mechanism. In 1952, French, however, certified also the involvement of sympathetic nerve system in G.I. tract bleeding with the experimental results. In addition to this report, many experimental works under the standpoint of hypothalamus involvement in stress ulcer were undertaken. On the other hand, hyperglycemia and glycosuria in the stress have been reported as the results of clinical and experimental works. In 1971, Frohman concluded that only ventromedial nuclei has relation to the control of glycogen metabolism in hypothalamus from his experimental results. We concluded that this hyperglycemia before the evidence of G.I. tract bleeding due to the involvements of hypothalamus or other parts of C.N.S. in the neurosurgical disease is one clinical sign of the stimualtion to sympathetic nerve system that also can be a cause of G.I. tract bleeding, and this hyperglycemia before the evidence of G.I. tract bleeding should be paid attention as a warning datum.

Brain tumors in infants and children are different from those in adults in type and location of tumor as well as accompanying complication. Given this fact, and the fact that these patients are under development, careful consideration is required for determination of treatment planning. Thus, we have investigated the curative results of brain tumors in infants and children and factors effecting prognosis. In this study, medulloblastoma which is one of the most malignant pediatric brain tumors was analyzed in 64 cases in light of mode of metastasis and prognosis. Among those cases, there were 23 cases which were diagnosed to have metastasis or infiltration of tumor from the original site of the fourth ventricle. As mode of the cerebrospinal fluid circulation, 6 intracerebral solitary metastasis, 1 entraspinal cord metastasis, 1 intraperitoneal metastasis via shunt and 7 generalized metastases involving bone in 5, lymphnodes in 2 and liver, spleen, kidney, lung and peintoneal cavity in 1 respectively. The survival rate in those 23 cases with tumor metastasis or infiltration was 63.6% in one year, 28.6% in two years and 11.8% in five years and the average survival year was 8.1 months in cases who died of these tumor metastasis. Six of them had tumor metastasis with in 6 months after the initial treatment(s). There was no significant correlations in rate or occurrence of tumor metastasis between group of total resection and of partial resection nor group of whole neuro-axis radiation and of local radiation.(ABSTRACT TRUNCATED AT 250 WORDS)

Brain tumors in infants and children are different from those in adults in type and location of tumor as well as accompanying complications. Given this fact, and the fact that these patients are under development, careful consideration is required for determination of treatment planning. Thus, we have investigated the curative results of brain tumors in infants and children and factors affecting prognosis. In this study, astrocytoma which is most frequently seen in infants and children was analyzed in 181 patients. One hundred forty three of them were diagnosed as benign astrocytoma; and the other 38, as malignant astrocytoma or glioblastoma. In respect of location, supratentorial tumors were seen in 73 patients, while subtentorial tumors occurred in 61; nine tumors infiltrated into both regions. The 5-year survival rate of benign astrocytoma was 50%, compared with 6.3% in malignant astrocytoma. As for relations to location of tumor, 66% of tumors which infiltrated into the supratentorial and subtentorial regions were malignant, and the prognosis was poor: the 5-year survival rate was 14.2%. The 5 year survival rate of subtentorial tumors was 38.9%, whereas that of supratentorial tumors was 57.6%. Analysis by age revealed that malignancy increased in proportion to age over 12 months after birth; between the ages of one and six years, the incidence of malignant tumors was 9% and the 5-year survival rate was 48%, while between the ages of 12 and 16, the rates were 29% and 14%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors report a 11-year-old girl with a huge intraspinal malignant teratoma associated with spinal arachnoid cyst. At seven year of age, suprasellar tumor was diagnosed and the patient received radiation therapy for tumor bed with total dose of 4,225 rads. As the result, marked decrease of the size of tumor was seen by follow-up CT scan. Serum alphafetoprotein (AFP) and human chorionic gonadotropin (HCG) level were at 51ng/ml and 31IU/l when total dose of 2,000 rads were over, and they decreased to 3ng/ml and 6.6IU/l at the dose of 4,225 rads respectively. The histology of the suprasellar tumor was unverified. She was discharged without any neurological deficits. For next 24 months, she received intrathecal administration of Methotrexate by repeated lumber puncture in 14 times. She remained intact neurologically. At eleven years of age, four years later, she started complaining of the right leg pain. On the examination, hypesthesia in the L distribution and stiff neck with positive straight leg raising test were observed. Urinary and bowel function were intact. CT scan of the head revealed residual of the suprasellar tumor but the size of the tumor was unchanged. Myelography showed complete block at the level of L. Laminectomy at L was performed and brownish cyst was found in the intradural space. Aspiration of cyst content and cyst wall resection were carried out. Histology of the cyst membrane was arachnoid and spinal arachnoid cyst was diagnosed. The postoperative course was uneventful until 13th postoperative day, when acute progressive paraparesis and numbness of bilateral toes were seen.(ABSTRACT TRUNCATED AT 250 WORDS)