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Median artery of the corpus callosum(MACC)refers to the median artery of the triplicate anterior cerebral artery(ACA). When MACC distributes to one or to both hemispheres, it is known as the accessory ACA. We performed detailed angiographic analysis of 32 consecutive patients operated upon for distal ACA(DACA)aneurysms, and noted that all DACA aneurysms occurring in the supracallosal portion were accompanied by an accessory ACA as vascular malformation. Such relationship between accessory ACA and DACA aneurysm in the supracallosal portion has not been previously reported.

We report the successful surgical treatment of a dural arteriovenous fistula(AVF)located in the lateral wall of the cavernous sinus. A 44-year-old woman presented with facial numbness in the left V3 area. Magnetic resonance imaging showed a flow void sign around the sphenoid ridge on a T2-weighted image. Digital subtraction angiography(DSA)demonstrated a dural AVF that was supplied by feeding arteries from the C4 portion of the left internal carotid artery. Without sinus enhancement, the draining vein flowed directly through the superficial sylvian vein into the vein of Labbé. Following treatment of the dural AVF located in the anterior cranial fossa, we ligated the draining vein at the penetrating point in the intradural region using surgical management. Intraoperative findings showed that the shunt point was located in the left lateral wall of the cavernous sinus. The postoperative course was uneventful and DSA showed no evidence of the AVF. The patient was discharged with no neurological deficits. Few studies have reported the use of direct surgery alone for the treatment of dural AVFs located in the cavernous sinus with a perfusion pattern as in this case.

A case of intracranial hemorrhage associated with injury of a critical diploic venous system in clipping for an unruptured cerebral aneurysm was reported. A 67-year-old female presented with a sense of floating. Magnetic resonance angiography (MRA) showed a C1-2 portion aneurysm of the left internal carotid artery 13 mm in size projecting supero-laterally. Three-dimensional CT angiography (3DCTA) volume rendering revealed a developed left fronto-anterior temporal diploic venous system draining the frontal cortical venous return. Because of the large and wide-necked aneurysm, we planned clipping surgery for the purpose of a complete cure. The operation was performed with left fronto-temporal craniotomy at the expense of the diploic venous system. Using techniques such as bipolar coagulation and suction decompression, neck clipping was accomplished via the distal trans-sylvian approach. After the operation, the patient was noticed to be delirious, and post-operative CT demonstrated intracranial hemorrhage in the left frontal lobe with severe brain edema. Motor aphasia was remarkable, but it was gradually relieved, and she left our hospital with no motor weakness. 3 months after the operation, her aphasia was faintly perceptible but she could live independently. We concluded that the injury of a diploic venous system could cause intracranial hemorrhage with intractable brain edema by critically interrupting the frontal venous return.

A 72-year-old man presented with gait disturbance and right homonymous hemianopsia. Magnetic resonance (MR) imaging showed a solid mass around the left cavernous sinus with rostral development of a multi-lobulated cystic component. The tumor was totally removed including the cystic wall via the left transsylvian approach with orbito-zygomatic craniotomy. Most of the tumor was attached to the lateral wall of the left cavernous sinus. Histological examination showed a meningioma WHO grade I with meningothelial meningioma formed lobules with intranuclear inclusions. His neurological symptoms disappeared immediately after the operation. Postoperative MR imaging revealed total removal of the tumor including the large cystic component.

The intracranial portion of the trigeminal branches is rarely involved in neurinomas. The clinical characteristics including symptoms, neuroradiological findings and results of surgical excision of the previously reported 11 neurinomas and the present case arising from the intracranial trigeminal branches are reviewed. A 59-year-old female patient complained of paresthesia and hypesthesia in the infraorbital region with no other neurological abnormalities. Neuroradiological examinations revealed a round cyst-like tumor located at the middle fossa with enlargement of the foramen rotundum and pterygopalatine fossa. No vascular abnormalities were found by angiography. At surgery, the solid tumor with no cystic component arising from the intracranial maxillary nerve was removed totally via a frontotemporal extradural and interdural approach with zygomatic osteotomy. Histopathology revealed a typical neurinoma. The paresthesia disappeared following surgery. Clinical features of neurinomas arising from the trigeminal branches are varied but distinct depending upon the site of origin of the tumors. These tumors can be removed totally in most cases through the extradural and interdural approach without critical morbidity. Special care should be taken not to cause injuries to the surrounding neurovascular structures such as cranial nerves and internal carotid artery. A small amount of residue is acceptable in cases of tumors with tenacious adhesion to these critical structures.

We described a case of systemic lupus erythematosus (SLE) complicated with multiple intracerebral hemorrhage. A 52-year-old female with no history of hypertension had been treated with steroid hormone therapy for more than 15 years. Four days before admission, she experienced acute onset of headache and nausea. On the day of admission, the patient suffered from headache and nausea again followed by a deteriorated level of consciousness. The computed tomographic scan revealed two subcortical hematomas in the right frontal and left temporo-occipital area with atypical findings compared to those of the usual intracerebral hemorrhage. Cerebral angiography demonstrated that cortical arteries around the hematomas were markedly stretched and displaced. Multiple segmental stenosis and irregular lumen of the internal carotid artery and bilateral cortical arteries were possibly representative of vasculopathy. Transit time of blood flow was severely delayed with no apparent obstruction of the cerebral arteries, veins and dural sinuses. These findings suggested the existence of severely increased intracranial pressure. Emergent surgical evacuation of the hematomas was successfully performed with a favorable outcome for the patient. Intraoperatively, the brain was congested even after the evacuation of the hematomas. Surgical manipulation was able easily to cause bleeding from the cavity of the hematomas, which was hard to control. It is supposed that vasculopathy including fibrinoid degeneration and vasculitis may have affected the susceptibility of small arteries and veins to rupture in the present case. Subsequent increase of intracranial pressure might cause another hematomas by adding of hemodynamic stress to small vessels apart from those at the site of the first hemorrhage.

A case of Turner's syndrome complicated with intracerebral hemorrhage in a 21-year-old female is presented. The patient experienced acute onset of unconsciousness and the left-sided hemiparesis due to the right-sided putaminal hemorrhage. Severe hypertension was seen at the hospitalization. Cerebral angiography revealed no vascular lesion other than the displacement of lenticulostriate arteries. Emergent surgical evacuation of the hematoma was successfully performed with her favorable outcome. Postoperatively, several hormonal tests indicated hyperaldosteronemia secondary to the increased levels of ACTH and renin as a result of hyper-response to the environmental stress, leading to critical hypertension. Other examinations including CT scan, MRI, MRA, and laboratory data showed no abnormalities suggestive of renal lesions. It is supposed that hypertension, as a frequent presenting feature, should be strictly controlled in Turner's syndrome from the first time of diagnosis.

Purpose: 5-hydroxytryptamine(5-HT) 1 A receptor agonists have a potentially marked neuroprotective reaction by both neuroprotective and hypothermic effects. We previously reported (1) the neuroprotective effect against the cerebral ischemia under normothermic condition, and (2) the hypothermic effect of the novel compound of 5-HT 1 A agonist, SUN N4057. The present investigation was designed to examine the enhancement of the neuroprotective effect by its pharmacological hypothermia., Methods: In 24 anesthetized cats(body weight 1.9-4.6 kg), the left middle cerebral artery(MCA) occlusion was performed via the transorbital approach. Just after MCA occlusion, SUN N4057(6 micrograms/kg/min) was infused. Physiological parameters were measured continuously, and arterial blood gas was analyzed hourly for 6 hours and maintained within the normal ranges. Animals were randomly allocated to the following three groups: (1) ischemic controls infused with sterile saline(Group A, n = 8), (2) SUN N4057 under normothermic condition(Group B, n = 8), (3) SUN N4057 (Group C, n = 8). Then, brain coronal sections of 3 mm in thickness were stained with 1% triphenyltetrazolium chloride(TTC) solution, and hemispheric infarct volumes were calculated by using a computerized image analysis system., Results: There were no significant differences in any physiological parameters among 3 groups. In Group C, brain temperature decreased significantly starting 1 hour after MCA occlusion and dropped by 2.1 +/- 0.7 degrees C 5 hours. Infarct volumes were 35.6 +/- 6.9% (Group A), 23.3 +/- 5.8% (Group B) and 12.3 +/- 11.3% (Group C), respectively. There were significant differences among three groups(p < 0.05)., Conclusion: On the basis of these data, we conclude that SUN N4057 provides more effective neuroprotection by the combination of hypothermic and neuroprotective effects. Chemical hypothermia may lead to a new therapeutic approaches for treatment of brain ischemia.

Spinal subarachnoid hematoma is a very rare event, occurring exclusively in the thoracic or lumbar region. We report the first recorded case of spontaneous subarachnoid hematoma in the high cervical spine presenting as Brown-Séquard's syndrome. A 57-year-old woman with no prior problems suddenly presented with Brown-Séquard's syndrome at the C1-2 disc space level following occiput neck pain. Her consciousness was clear and urinary retention was not observed. Lumbar puncture revealed no evidence of hemorrhage. Neuroradiological evaluation, including myelography, CT myelography, and MRI, demonstrated a defined hematoma in the cervical subarachnoid space at the C1-2 level. Angiographical study yielded negative findings. The patient's neurological state remained unchanged for the following 6 days. On the 7th day from the onset, a C1 and C2 laminectomy was performed. A defined clot was found after incising the intact dura matter and arachnoid membrane. This clot was easily aspirated except for a small part which was found attached to a pial vessel on the dorsal surface of the spinal cord. No underlying pathology other than coagulated blood was confirmed. Three months postoperatively, she had no neurological deficits. The clinical course of spontaneous spinal subarachnoid hematoma varies according to the rapidity and severity of hematoma formation. An immediate and precise diagnosis using multimodal neuroimagings is vital because decompressive surgery can dramatically ameliorate the neurological sequelae.

The occasional occurrence of dissemination and tumor-associated hemorrhage from glioblastoma is well known and widely reported in the literature. The authors present a case of cerebral glioblastoma with dissemination possibly caused by intratumoral hemorrhage. Computed tomographic (CT) scan revealed a small hemorrhagic lesion in the right frontal lobe and a sylvian fissure in a 62-year-old man who complained of sudden headache. Four months later, he again presented with neck pain followed by weakness and numbness in the extremities. Magnetic resonance images (MRI) of the cervical spine demonstrated multiple enhanced tumors. After transfer to our institution, a large cystic tumor with ring-like enhancement was found in the right frontal lobe. Progressive neurological deficits prompted an operation on the cervical tumors and a pathological diagnosis of anaplastic astrocytoma with a negative reaction for glial fibrillary acidic protein (GFAP) was made. Intraoperative findings of the second operation for the cerebral tumor disclosed that the tumor extended outside the frontal lobe, growing substantially within the sylvian subarachnoid space and involving middle cerebral artery branches. The results of a pathological study were those consistent with glioblastoma having tumor cells with little positive reaction to GFAP staining. Craniospinal radiation was undertaken as a palliative treatment of the residual tumor. On MRI, multiple nodular dissemination in the lumbo-sacral region was diagnosed. Two months later, the patient suddenly lost consciousness and suffered eye deviation. A CT scan found a large tumor-associated hemorrhage in the right frontal lobe. Emergency evacuation of the hematoma with gross total removal of the residual tumor was performed. He temporarily returned to his preoperative neurological condition but died later due to the recurrent cervical tumor. Dissemination secondary to intratumoral hemorrhage in patients with glioblastoma has not been reported. This rare case shows that hemorrhagic glioblastoma is at risk for dissemination, especially when the hemorrhage occurs in or near the subarachnoid space and tumor cells have a less positive reaction for GFAP staining.

We described a surgical case of growing cavernous angioma located at the pontomedullary junction. This 52-year-old woman presented with symptoms caused by a small hemorrhage in the right cerebellopontine angle. Magnetic resonance images (MRI) suggested cavernous angioma as the underlying pathology. 9 months after the first episode, the second hemorrhage occurred with a deteriorated neurological state that disappeared under conservative treatment except for right facial paresis and hearing disturbance. During careful observation for 1 year, the size of the lesion gradually increased on MRI and additional neurological deficits including left hemiparesis and right abducent nerve palsy were diagnosed. The first operation was carried out through the right lateral suboccipital approach, but only partial removal of the cavernous angioma was accomplished due to the overlying seventh and lower cranial nerves. After more than 4 months, a third hemorrhagic episode was presented with a sudden onset of right cerebellar signs and facial numbness. The cavernous angioma grew in size to reach the ventrolateral corner of the 4th ventricle with dense hemosiderin deposition around the core lesion on MRI. An enhancement inside the lesion was also demonstrated after gadolinium-diethylenetriaminepenta-acetic acid administration. The second operation through the midline suboccipital approach was selected for the complete resection of the residual cavernous angioma. The lesion was too hard to resect without internal decompression. The pontine part of the lesion was almost totally resected, but manipulation for the medullary part to create a discrete layer between the lesion and surrounding neural tissues was unsuccessful and generated severe bradycardia, so this part of the cavernous angioma had to be left. The problems for the management of cavernous angioma in the brain stem should be discussed, especially focussing on the surgical indication in reference to our experience and previous literatures.

The authors reported two cases of aneurysms associated with von Recklinghausen's neurofibromatosis. The first case, a 60-year-old woman was referred to our hospital because of disturbance of consciousness and right hemiparesis of acute onset. On admission, she was almost alert but developed right hemiparesis and lower cranial nerve palsy. Computed tomographic (CT) scanning and magnetic resonance imaging (MRI) demonstrated a huge mass compressing the brain stem and another mass lesion in the suprasellar cistern. Cerebral angiography disclosed left vertebral and left internal carotid artery giant aneurysms. Since she suffered respiratory distress because of aspiration pneumonia, conservative therapy was carried out. However, she developed cardiac arrest suddenly and died fourteen days after admission. On autopsy, it was shown that the left sided medulla oblongata had necrosis due to compression by the giant aneurysm and that the hemorrhagic infarction of the left cerebellar hemisphere was caused by a thrombus from the giant aneurysm of the left vertebral artery. The second case, a 40-year-old woman presented a disturbance of consciousness. A CT scanning demonstrated subarachnoid hemorrhage with a thick hematoma in the left sylvian fissure. An aneurysm at the junction of the right internal carotid artery and the posterior communicating artery was found, while the left middle cerebral artery was shown to be normal on cerebral angiography. Additionally an arteriovenous fistula of the left vertebral artery was found. Although no aneurysm was seen in the territory of the left internal carotid artery, left sided craniotomy was performed based on the CT findings.(ABSTRACT TRUNCATED AT 250 WORDS)

We reported a case of chronic encapsulated intracerebral hematoma associated with cavernous angioma. A 71-year old female was admitted with a history of frontal headaches at intervals of about 3 months for the last one year. Plain CT scan showed a round mass of heterogeneous high density in the left medial frontal lobe. The outer surface of the mass was enhanced with contrast material. MRI demonstrated the mass as a high signal intensity on T1-weighted image and low intensity with laminated structure on T2-weighted image. MR angiogram depicted the mass as a mottled high signal intensity. The left internal carotid artery angiogram revealed no abnormal shadows and vessels. These findings suggested some form of a thrombus although its underlying pathogenesis was unclear. On January 20, 1992, a bifrontal craniotomy was performed. A whitish well-demarcated mass was seen in the left cingulate gyrus through a small corticotomy. We could not identify any branches feeding the mass. The cross-section of the mass disclosed a uniform thrombus encapsulated by a thick wall. Histological studies of the wall confirmed a cavernous angioma within the outer collagenous layers. Chronic encapsulated hematoma, which was first reported by Hirsh in 1981, has represented a separate entity and 25 such cases have been documented in the literature. These reports suggested that the compression and/or destruction of the surrounding tissue caused by the hemorrhage would mask the existence of the cavernous angioma or vascular malformation. If an encapsulated hematoma were encountered during an operation, surgeons should pay attention not to overlook the residual capsule encompassing the cavernous angioma or vascular malformation.

We report a rare case of germinoma with granulomatous reaction arising from the corona radiata. This 20-year-old man was admitted to our hospital complaining of progressive motor weakness on the right side. CT demonstrated a poorly demarcated high density area in the left corona radiata, which was heterogeneously enhanced after administration of contrast medium. Moreover, the continuity of the mass to the ventricular wall was confirmed on MRI. At the first operation, subtotal removal of the tumor was performed through a fronto-parietal craniotomy. The diagnosis for the specific neoplasm was not established histologically, but granuloma caused by fungal infection was the most likely cause of the lesion. We tried amphotericin B (AmB), and remission of the tumor was obtained. However, during the following 3 months, the size of the tumor gradually enlarged again. AmB was repeatedly administered, but this time the treatment was ineffective. Six months later, on May 21, 1990, the second operation was performed and histological examination revealed typical germinoma consisting of two-cell pattern. Subsequently, the patient underwent focal irradiation of 33 Gy to the tumor site, and the tumor completely disappeared. As intracranial germinomas are observed to be successfully cured by radiotherapy and/or chemotherapy, choice of the therapeutic management must be carefully determined according to the histological diagnosis, especially in young people. A variety of locations of germinomas and the accompanying granulomatous reactions could create some diagnostic confusion, so great care must be taken in the treatment of much intracranial germinomas.