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A case of solitary neurinoma of the trochlear nerve was reported. The patient was a 37-year-old female, who had a sudden attack of right-sided temporal headache with nausea and vomiting on August 1, 1982. Headache was subsided in a few days but she had complained of diplopia since the episode. Ophthalmological examination revealed right superior oblique muscle palsy. She was neurologically free otherwise. CT scan, taken about three weeks after the onset, showed a solitary enhancing mass in the region of tentorial incisura on the right side. She was admitted to our clinic on August 24, 1982. Extensive work-up including polytomography, cerebral angiography, lumbar puncture, and so forth, revealed no abnormality. There were no cutaneous manifestations of von Recklinghausen's disease. Craniotomy was performed on October 28, 1982 and the tumor was totally removed by way of right subtemporal-transtentorial route. The tumor, size of which was 1.0 X 0.9 X 0.7 cm, was located just underneath the tentorial edge, and was adherent to it. The trochlear nerve was found incorporated in the tumor. Histological diagnosis was neurinoma of Antoni A type. Postoperatively, she was well and fully active, except for diplopia due to the sacrificed trochlear nerve.

An attempt was made to collect the cerebrospinal fluid (CSF) of rat using a capillary phenomenon technique. Experiments were carried out in 76 rats anesthetized with pentobarbital sodium (Nembutal, Abbot. 50 mg/kg IP). The midline incision in the occipital region was made from 0.5 cm anterior to interauricular line of 4 cm in length. Exposing the atlanto-occipital dura mater by separating the nuchal muscles, the CSF was collected with a heparinized microtube (MICROPET. Bection, Dickson and Company) through a small hole made by a 18G syringe needle. Thus, 0.05-0.05 ml of the CSF could be readily obtained without mixture of the blood in 64 cases out of 76 trials, 84%. This simple technique is a useful way to get a small amount of CSF from little animals, such as rats.

In the previous report, the authors described a method obtaining numerical values of 'standard deviation (SD)' and deviation coefficient (DC) from printed out data of a brain CT slice picking up the basal ganglia. In the report, using these values, a possibility of numerical discrimination between normal and abnormal was also discussed. In the present investigation, it was attempted to apply admissible linear discriminant analysis to numerical diagnosis using SD value and DC value. From fifty normal scans and fifty abnormal ones of proved pathology, the admissible linear discriminant function, as below, was extracted, its misdiscriminant rate being 7.6% theroretically. S=-0.4248(SD)-6.4709 (DC) S larger than or equal to -11.447; normal, S < -11.447; abnormal. By this analysis, 98% of abnormal scans and 92% of normal scans were correctly judged without referring to analogue display and actual misdiscriminant rate was 5.0%. Furtermore, for the purpose of confirming reappearance of this result, another twenty normal scans and twenty abnormal scans were investigated by this method. Only one normal scan was judged uncorrectly and all abnormal scans were judged correctly. Accordingly misdiscriminant rate of this sample was 2.5%. It would be emphasized that this method was useful for screeing examination by CT, not only because the total discriminant rate was high, but also false negative rate was relatively low.

In 168 patients with ruptured intracranial aneurysms, the pathology of intracranial hemorrhage visualized on CT was analyzed. Blood in the subarachnoid space could be visualized in 95% of cases within three days after SAH and 75% of 106 cases within two weeks after SAH. In one case blood clot in the subarachnoid space visible up to 13 days after SAH. Concerning the cases within two weeks after the bleeding, intracerebral hematomas were observed in 36% of anterior cerebral aneurysms and middle cerebral aneurysms, 16% of internal carotid aneurysms and none of vetebro-basilar aneurysms. The incidence of the intraventricular hemorrhage was as follows; vertebro-basilar, 44%; anterior cerebral, 38%; internal carotid, 28%; middle cerebral, 12%. On the basis of the pattern of distribution of extravasated blood the location of the ruptured aneurysm was properly predicted in 58% of anterior cerebral, 81% of middle cerebral, 58% of internal carotid and 30% of vertebro-basilar. Especially CT could contribute to predict which aneurysm has ruptured in patients with multiple aneurysms. It was possible to localize the site of bleeding in 11 out of 12 CT positive cases. The development of intracranial hemorrhage demonstrated by CT well correlated with the clinical grading of the patients and the clinical outcome. Patients merely showing subarachnoid hemorrhage were more likely to have good neurological grades, but ones showing complicated intracerebral hematomas and intraventricular hemorrhage had poor neurological grades at the time of the scan. The findings of extensive subarachnoid clot, which were followed by severe vasospasm, and marked intraventricular hemorrhage, usually correlated with poor prognosis. These pathology recognizable on CT was very helpful in determination of the timing of surgery and management of such patients. In conclusion CT is of great value in the examination of SAH when performed in the acute stage and should be the initial examination followed by angiography.

To clarify the pathogenesis of normal pressure hydrocephalus (NPH), quantitative measurement of CSF dynamics was attempted using RI techniques. In this study results concerning RI ventriculography and RI transfer test from CSF to plasma were reported. "Barrier ratio" and regional cerebral blood flow study in NPH will be reported elsewhere. Fifty-three patients with chronic communicating hydrocephalus wer devided into two groups. Thus, twenty-seven cases were diagnosed as NPH according to clinical symptoms and signs, and others were considered as mere chronic communicating hydrocephalus without any NPH characteristics. Results are as follows: 1) 169Yb--DTPA ventriculography; In NPH group, there was longer retention of RI injected into lateral ventricle, and RI activity was not detected in the cisterna magna 60 minutes after the injection. These findings show remarkable delay of CSF flow in NPH patients. 2) Transfer test of 169Yb--DTPA from CSF to plasma; Immediately after the RI injection, Transfer ratio of RI activity from CSF to plasma was measured. It was revealed that intraventricular RI was more rapidly transfered to plasma in NPH group compared with in the control group, suggesting accelerated trans-ependymal absorption of RI in NPH group.

Findings of computerized tomography (CT) in 183 cases of head injury in children were investigated with special reference to CT findings of mild head injury. As was expected, CT findings of mild head injury fell within the normal range, in almost all cases. However, abnormal findings were noticed in 4 out of 34 cases (12%) in acute stage and 7 out of 76 cases (9%) in chronic stage. They were 3 cases of localized low density area in acute stage and 6 cases of mild cerebral atrophy in chronic stage, etc. There were some cases of mild head injury in which CT findings were normal while EEG examination revealed abnormality. Also in some cases, x-ray study demonstrated linear skull fracture which CT failed to show. These conventional techniques could be still remained as useful adjunct aid in diagnosis of head injury. CT findings of cases of cerebral contusion in their acute stage were divided as follows; normal, low density, small ventricle and ventricular and/or cisternal hemorrhage, frequency of incidence being 38, 17, 22, 11% respectively. These findings were invariably converted to cerebral atrophy from 10 days to 2 months after the impacts. In the cases with intracranial hematoma revealed by CT, only 32% of them showed clinical signs of Araki's type IV in their acute stage and 63% of them showed no neurological defects, that is Araki's type I & II. A case of extreme diffuse cerebral atrophy which followed acute subdural hematoma caused by tear of bridging veins without cortical contusion was presented.

A case of cheiro-oral syndrome presumably due to brain stem infarction was reported. A 41-year-old man suddenly experienced the numbness of the palm and the lips on the left side at 2 p. m. March 30, 1982 and was admitted to our clinic at 5 p.m. on that day. Neurological examination on admission revealed hypesthesia of the palm and the lips on the left side, but pain and temperature sensibilities were preserved. Neither astereognosia nor extinction phenomenon was there. CT scan showed no abnormal findings. At 9 p.m. his speaking became somewhat obscure and he became unable to swallow fluid. And after ten hours or so, he became quadriplegic, anarthric and lost almost all voluntary movement below the eye, while his consciousness was preserved ("Locked-in" syndrome). CT scan taken on the 9th hospital day revealed brain stem infarction. He expired on the 58 th hospital day because of the exacerbation of pneumonia. At autopsy both vertebral arteries and basilar artery were markedly sclerotic. The rostral two-thirds of the basilar artery was occluded by organized thrombus. The serial microscopic sections through the midbrain and the medulla oblongata showed extensive infarction of the basis pontis. The tegmentum pontis remained free, except that a small offshoot of the infarct reached into the medial part of the medial lemniscus.(ABSTRACT TRUNCATED AT 250 WORDS)

Computerized transverse axial tomography (CT) of the brain is a recently developed method which allows non-invasive roentgenologic evaluation of intracranial diseases. The advent of CT represents a great advance in the diagnosis of a very wide variety of intracranial lesions, including cerebrovascular diseases. Especially, CT was found to be extremely informative in evaluating intracerebral, intracerebellar and intraventricular hemorrhage. The purpose of this report is to evaluate the clinical usefulness of CT in the diagnosis of intracranial hemorrhage. From the seven hundreds cases of various intracranial diseases hitherto examined by the EMI-scanner (160 X 160 matrix), twenty-three cases of nontraumatic intracranial hemorrhage were selected for the present study. Fifteen cases of fresh hemorrhage consisted of hypertensive cerebrovascular disease, arterio-venous malformation, aneurysm and unknown etiology, number of cases being six, three, four and two, respectively. All cases were examined within fifteen days after the ictus and the positive findings were obtained in all cases. The characteristic feature of the hematoma is the circumscribed and increased density area surrounded by the decreased density zone probably representing the accompanied brain edema. The sequential CT studies revealed that the hematoma area was gradually decreased in its density and finally transformed into the rather low density one in four weeks or so after the ictus. The smallest hematoma detected by CT was the cerebellar hematoma about five grams in weight, which was failed to be recognized by the angiography. In cases of the old hemorrhage, besides the decreased density area of the hematoma, such findings were obtained as cerebral atrophy, ventricular dilatation and porencephalic change. It would be concluded that CT study is the most useful aid at present available in the diagnosis of intracranial hemorrhage. The precise anatomic extent of the hematoma, associated brain edema, ventricular deformity and displacement and hydrocephalus are all readily assessed by CT.

The aim of this report is to assess the possibility of digital processing of computed tomography for histological diagnosis of brain tumors. For this purpose, percent histograms of x-ray attenuation value of lesions were analysed in 113 cases of histologically verified hemispheric tumors. Sixteen histograms obtained from normal brain parenchyma served as controls. Histograms were made from the same slices before and after contrast enhancement. The result were as follows; Histograms of benign tumors such as meningiomas and low grade astrocytomas characteristically showed similar pattern with normal subjects, whereas histographic patterns of the more malignant tumors such as malignant astrocytomas, metastases and glioblastomas were more heterogeneous with lower peak and wider curve. Displacement of the histogram to the higher density following contrast material administration was important clue in histographic analysis. The most prominent displacement was observed in meningiomas, followed by metastases with nodular type enhancement and malignant astrocytomas. Displacement in low grade astrocytomas and oligodendrogliomas was very slight and less than that of normal brain. Tumors showing ring enhancement such as glioblastomas and brain abscesses had wide histogram curve with twin peaks. Conclusively, it is possible to detect histological nature of cerebral tumors through CT scanning, using histographic analysis of the digital data.

A 15-year-old girl was admitted to our clinic on July 16, 1985 with the epilepsy which had been resistant to various anticonvulsant therapies. At the age of 10 years automatism seizure, characterized by purposeless movement of arms and head of which the patient was unaware, began to occur and became as frequent as two to three times each day. From the age of 13 years, there were also grand mal seizures several times a year in spite of medical treatment. She had normal delivery and no history of febrile convulsion. There was no family history of epilepsy or mental disease. When examined on admission, she had normal personality and intelligence. There was no neurological abnormality. She complained of sleepiness and hirsutiness. Fit of automatism occurred two to three times a day during admission, though the blood levels of anticonvulsant drugs such as phenobarbital, phenytoin and carbamazepine reached to therapeutic concentration. EEG examination including infratemporal lead recording showed right temporal spike focus. But all the neuroradiological studies such as skull X-rays, CT, cerebral angiography and magnetic resonance imaging failed to show abnormal finding. Right temporal lobectomy was carried out under general anesthesia on Aug 22, 1985, and anterior two-thirds of the middle and the inferior temporal gyri were resected deeply to anterior hippocampus. To the naked eye, no abnormal finding was noted during the operation. In the surgical specimen, macroscopically nothing abnormal was found. Microscopically, serial sections of the lobe revealed clusters of oligodendroglial cells in cortical to subcortical region of the medial basal part of the temporal lobe.(ABSTRACT TRUNCATED AT 250 WORDS)

Although the cerebral blood flow dynamics in cerebral infarction has already been studied by many investigators, the CSF flow dynamics in cerebral infarction has not been well discussed. The purpose of this paper is to investigate CSF flow dynamics in chronic cerebral infarction by RI cisternography and our new quantitative method. In 12 patients with cerebral infarction, the flow of CSF was estimated following intrathecal injection of 169Yb-DTPA or 111In-DTPA. In this study, in addition to the conventional cisternograms, quantitative evaluation of CSF flow was performed in 6 patients by our method. Our previous work included the quantitative CSF flow dynamics in 26 various cerebral disorders using RI Anger camera. This method consisted of following procedure: 30 minutes after RI injection, RI activity was studied continuously for 30 minutes, afterwards playing back the record to calculate the changes of RI activity in the optimal regions of interest. These operations were performed with Anger camera, accessory digital ratemeter and tape-recorder. The changes of RI activity which appeared to be linear is called flow rate in our study for convenience. In this report, the region of interest was selected at Sylvian cistern. 6 patients had abnormal cisternograms consisting of reflux of tracer into the ventricle and delayed migration of tracer to the basal cisterns and diminished flow of tracer in the affected hemisphers. In 5 patients whose cisternograms could not demonstrate the laterality of RI perfsion over the cerebral hemishere, a marked difference of flow rate between right and left Sylvian cisterns was found. These findings probably indicated the correlation between cerebral blood flow dynamics and CSF flow dynamics in cerebral infarction. Moreover, it was confirmed that our method could be of clinical use to evaluate CSF flow dynamics quantitatively. The possible mechanisms of CSF flow disturbance in the affected hemisphere following cerebral infarction was discussed.

In the previous report, it was insisted that traumatic intracerebral hematoma should be regarded as a variety of cerebral confusion and that conservative treatment would be therapy of choice in these situations. Adversely, unjudicious operation would sometimes result in more expansion of hematoma by untamponade effect of decompressive craniectomy. In the present investigation, it was attempted to provide therapeutic policy in the management of traumatic intracerebral hematoma. Consecutive thirty two cases of traumatic intracerebral hematomas were selected for this study. Those cases with other hematoma such as epidural or subdural hematoma were excluded. These 32 cases were divided into two groups, operative (15 cases) and non-operative (17 cases). Whether to be operated or not was arbitrarily decided by the surgeons who were faced to the patients. Disturbance of consciousness of the patients were divided into three categories, namely severe (III-100 to 200 level), moderate (II-10 to 30 level), and mild (I-1 to 3 level). They were 8 cases, 5 cases, 1 case in operative cases and 6 cases, 10 cases, 1 case in non-operative cases respectively. Mortality rates were 13.3% (2 cases) in operative cases and none in non-operative ones. Concerning the patients of severely disturbed consciousness, there were no difference in their final outcomes between the two groups. On the other hand, 7 out of 10 cases of moderately disturbed consciousness recovered completely without operation, whereas all operative cases of the same category were, more or less, handicapped.

Using RIA technique, response patterns of ACTH-adrenocortical system to short term large dose corticosteroid therapy for neurosurgical patients were investigated. The subjects were consisted of 20 males and 13 females, ageing ranging from 10 to 60 years old. The subjects were divided into three groups according to mode of steroid administration. In the first group, 12 mg/day of betamethasone were administered for 5 days and cancelled without gradual reduction. In the second group, 12 mg/day of betamethasone were administered for 4 days and 6 mg/day of betamethasone were given for following 2 days. In the third group, 12 mg/day of betamethasone were administered for 3 days and gradual reduction of betamethasone was given for following 4-5 days. Response of plasma cortisol level to synthetic 18-ACTH were measured in all patients for 3 days after betamethasone administration cancelled. The results led to the following conclusion. 1) The second and third groups had not any clinical symptom after steroid cancelled, but one half cases of the first group had mild headache, nausea for 2 days after cancelled. 2) Recovery process of adrenocortical function in the second group is most rapidly, compared with that in other two groups. 3) In the postoperative steroid therapy in neurosurgery, it could be concluded that 4 days massive administration of steroid followed by stepwise reduction in 2 days would be functionally well tolerated by adrenocortical system.

A case of craniopharyngioma with a large cyst extending through the posterior fossa down into the upper cervical spinal canal was reported. The patient is a 14-year-old female who was operated on for the first time in 1970, because of a suprasellar calcified mass. Histological examination verified craniopharyngioma of adamantinomatous type. Since then, she had been operated three times because of deterioration of visual acuity. She was admitted for the fifth time in January, 1977, complaining of severe neck pain radiating bilaterally to the shoulders. Radiological examination demonstrated, besides the suprasellar tumor, a huge mass extending along the clivus down to the level of C3 of spinal canal. Anteroposterior diameter of bony spinal canal evidently enlarged in upper cervical region. Interpedicular distance also widened markedly in the same region. Laminae of C1-C3 vertebrae were abnormally stretched and the spinal cord was compressed posteriorly by the tumor. Suboccipital craniectomy verified a cystic tumor in the region of foramen magnum and cervical spinal canal. The medulla oblongata was pushed backward by the tumor. The cystic tumor was evacuated and the capsule of the tumor was partly resected, which was histologically verified as craniopharyngioma of squamous type. The patient was relieved from the neck pain after operation and discharged in April 1977.

In the previous report the theoretical background and technical details of the isocount scanning were described. Based on clinical experiences of various brain diseases, the newly developed scanning method was confirmed to be more useful than the conventional scintiscanning. Besides the new scanning method, a new display system was also developed for the sake of more precise analysis of the isocount scanned data. This display method is called multilevel analysis or multilevel slicing of the scanned data. In the present investigation, this method was applied to thirty-two cases of cerebrovascular diseases, including seven cases of cerebral arterio-venous malformation, four cases of hypertensive intracerebral hemorrhage and twenty-one cases of cerebral infarction, positive rates being 86%, 100% and 90% respectively. In case of arterio-venous malformation, minimum size detected by the isocount method was 2 cm in diameter. To twenty one cases of the cerebral infarction, total thirty two scanning examinations were performed, including postictal follow up studies. It is often said that it is two or three weeks after the ictus when the infarcted cerebral lesion is most clearly detectable by the scintigraphic procedures, presumably due to focal neovascularizations which may occur in the lesion most prominently at this postictal stage. Contradicted to the current concept, our experiences show that abnormal dot accumulations are recognized in the scintigrams even at the earlier stage, thus among five cases of cerebral infarction scanned within a week after the ictus positive figures were obtained in four cases, two of which were examined within two days after the ictus. Focal breakdown of blood brain barrier at the acute stage is considered to be responsible for the early positivity in cerebral infarctions. In eight cases among twenty one cerebral infarctions angiographies failed to demonstrate the vessel occluded. The isocount scanning method, however, succeeded in getting positive results in seven of the eight cases. It will be emphasized that the isocount scanning is a preferable diagnostic procedure in the cerebrovascular diseases, especially when the angiography is hesitated to be performed because of the patient severely affected.

An 11-year-old boy was admitted to our clinic with complaint of headache. On admission he was in drowsy state and neurological examination revealed minimal motor weakness of the right hand. Plain skull roentgenogram demonstrated a thinning of the left temporal bone and elevation of the left sphenoidal wing. CT showed marked displacement of the midline structures from left to right. The left lateral ventricle was collapsed. A well circumscribed, homogenous, high density area was delineated in the left middle fossa. Contrast enhancement was negative. A-P view of left CAG showed a crescent shaped subdural avascular area in the parietal region. The anterior cerebral artery was roundly shifted from left to right. Chronic subdural hematoma due to bleeding of arachnoid cyst was most likely. Subdural collection was evacuated by trephination. The postoperative course was uneventful. Postoperative CT 3 week after operation delineated the arachnoid cyst more clearly as round low density area. Follow-up CT 6 months later showed the arachnoid cyst markedly reduced in size.

In the previous study, quantitative analysis of RI ventriculography was reported in fifty-three cases with chronic communicating hydrocephalus. In this study, according to the same criteria as that of previous report, fifty-three cases were divided into two groups, namely NPH group (twenty-seven cases) and control group, which were considered as mere chronic communicating hydrocephalus without and NPH chalacteristics. (twenty-six cases). Results of "barrier ratio (B.R.)" measurement and regional cerebral blood flow study in these cases are as follows: 1) "Barrier ratio" using of 99mTcO4-: Concerning about B.R. of 99mTcO4- there was no significant difference between NPH and control group. However it tends to be that shunt surgery is not so effective in NPH cases in which B.R. shows abnormally low value. 2) rCBF by 133Xe clearance method: Regional cerebral blood flow was diffusely decreased in NPH patients, especially in its frontal area, suggesting the frontal area would be more severely damaged in NPH cases. These findings leads us to the conclusion that whether the shunt surgery might be effective or not depends on severity of cerebral dysfunction and the cerebral dysfunction is clearly evaluated by RI technique mentioned above.