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In elderly patients with aneurysmal subarachnoid hemorrhage (SAH), complications including vasosopasm, subdural effusion, and late hydrocephalus, are liable to occur even after aneurysmal surgery. We examined prospectively the efficacy of arachnoid plasty using fibrin glue membrane during surgery of ruptured aneurysms in the elderly patients for preventing complications. The effects on the modified Rankin scale (mRS) and the Glasgow outcome scale (GOS) 3 months after SAH were noted.Total of 31 patients aged more than 70 years selected from a consecutive series of patients with aneurysmal SAH, were divided into two groups alternately, a group with arachnoid plasty (n = 16) and a control group without arachnoid plasty (n = 15). Statistical analyses were performed to assess relationships among various clinical and neuroradiological variables, especially between arachnoid plasty and occurrence of symptomatic vasospasm, subdural effusion, late hydrocephalus, or outcome such as mRS and GOS 3 months after onset.Statistical analyses revealed that arachnoid plasty were associated with late hydrocephalus and subdural effusion negatively, but with better mRS at 3 months after SAH. A tendency to be associated with less frequent symptomatic vasospasm was also noted.Arachnoid plasty using fibrin glue is suggested to be effective in preventing complications associated with SAH and aneurysmal surgery. A better outcome in the elderly patients can be achieved.

In this study the hemodynamic status and treatment modality of aggressive dural arteriovenous fistulas (dAVFs) was evaluated. Of 145 intracranial dAVFs treated in our clinic, there were 38 aggressive lesions presenting with hemorrhage, infarction, seizures, and symptoms of increased intracranial pressure. They included 3 (5% of all cavernous sinus lesions) cavernous sinus, 24 (44%) transverse-sigmoid and superior sagittal sinus, and 11 (46%) direct cortical types of dAVFs. Of these 38 aggressive lesions, retrograde leptomeningeal venous drainage was disclosed in 35 lesions, and retrograde sinus drainage in 3. Eighteen cases were treated only with endovascular procedures, 7 with surgical interventions, and 13 with combined endovascular and surgical procedures. Angiographic results were complete obliteration in 66% of the cases, subtotal and partial obliteration in 34%. Clinical outcome was GR (good recovery) in 58% of cases, MD (moderate disability) in 18%, SD (severe disability) in 13%, VS (vegetative state) in 8%, and D (death) (due to acute cardiac infarction) in 3%. Symptomatic procedural complication occurred in 3 cases. In conclusion, aggressive dural AVF resulted from retrograde leptomeningeal venous drainage. Combined surgical and endovascular treatment played the leading part in the management of this aggressive type of lesion.

A 50-year-old man had undergone right nucleus ventrointermedius (Vim) thalamotomy 1 year previously, resulting in the disappearance of left hand tremor. However, he presented with right distal and proximal tremor including the axial trunk, neck, and head. Deep brain stimulation (DBS) of the left Vim for these symptoms was unsuccessful. Attempts were made to stimulate the left Vim, nucleus ventralis lateralis, and subthalamic nucleus (STN), but no significant improvement was obtained after repeat surgery. However, subsequent improvement of the symptoms including proximal tremor was very marked even without DBS stimulation. Brain magnetic resonance imaging demonstrated lesion and edema in the posteromedial area of the STN. Mechanical injury of the area caused by the surgical procedures may have contributed to the improvement in his persistent symptoms.

Nuclear factor (NF)-kappaB is known to control cellular proliferation and apoptosis. In malignant astrocytoma cells, it was reported that NF-kappaB was activated aberrantly and promoted their proliferation. Thus, inhibition of NF-kappaB activity is considered to be a promising therapeutic strategy for malignant astrocytoma. Recently, curcumin, the major constituent of turmeric, was reported to inhibit NF-kappaB activity. In this study, we investigated inhibitory effects of curcumin on NF-kappaB activity and cellular proliferation, and induction of apoptosis by curcumin in human malignant astrocytoma cell lines. Alteration of NF-kappaB activity in NP-2 human malignant astrocytoma cell line after treatment with curcumin was examined using electrophoretic mobility shift assay. Alterations of DNA synthesis and cellular growth in five human malignant astrocytoma cell lines after treatment with curcumin were examined using [(3)H]thymidine incorporation assay and the trypan blue dye exclusion method, respectively. Induction of apoptosis by curcumin in NP-2 and NP-3 human malignant astrocytoma cell lines was examined by DNA-fragmentation analysis and morphological observation. We found that the NF-kappaB activity in NP-2 was significantly reduced by curcumin. The DNA synthesis and the cellular growth were inhibited by curcumin in dose-dependent manner in all the five malignant astrocytoma cell lines. Nuclear condensation and fragmentation, and DNA fragmentation were observed in both NP-2 and NP-3 after the treatment with curcumin. These results indicate that curcumin inhibits the cellular proliferation and induces apoptosis in human malignant astrocytoma cell lines. These results are considered to be resulted from the inhibition of NF-kappaB activity by curcumin.

OBJECTIVE: Neuro-endoscopy is playing a greater role in the diagnosis and treatment of several types of lesions, especially in the ventricular system. However, surgical planning and intraoperative orientation during endoscopic surgery are sometimes difficult. The efficacy of a neurosurgical navigation system using three-dimensional computer graphics of magnetic resonance (MR) images in neuro-endoscopic surgery was evaluated in this study. METHODS: We have developed a navigational endoscopic system designed to monitor the tip and direction of the endoscope, with the mirror marker of the navigation connected to a rigid endoscope. Eight patients, 3 cases of aqueductal stenting for isolated fourth ventricle, 3 cases of cystostomy for ependymal cyst, 1 case of septostomy for isolated lateral ventricle, and 1 case of ventricular tap in narrow ventricles, underwent endoscopic surgery using the present system. RESULTS: All patients underwent successful procedures with good outcomes. The present system was very useful in the cases of an accurate ventricular tap in narrow ventricles, identification of anatomic structures, and determining the appropriate route to the target point. CONCLUSIONS: This navigational endoscopic system improved the safety and accuracy of neuro-endoscopic surgery.

Preoperative magnetic resonance imaging of 4 cases of quadrigeminal cistern arachnoid cyst were retrospectively reviewed and patterns of extension to surrounding cisterns from the quadrigeminal cistern were examined. Relationship between patterns of extension to surrounding cisterns and selected surgical approach were evaluated. In 2 cases, the cyst extended anteriorly and compressed the quadrigeminal plate. These two cases had hydrocephalus due to aqueductal stenosis. The anteroirly extending cyst was treated with endoscopic ventriculocystocisternostomy via the lateral and third ventricles. In one case, the cyst extended superiorly to the velum interpositum cistern, and was treated with endoscopic ventriculocystocisternostomy via the lateral ventricle. In one case, the cyst extended laterally to the ambient cistern and compressed the posterior horn of the lateral ventricle. This case had loculated hydrocephalus of the inferior horn. The laterally extending cyst was treated with resection of the wall of the arachnoid cyst via an infratentorial supracerebellar approach assisted by endoscope. All cysts were successfully treated. Injury of the foramen of Monro occurred during a procedure using a flexible endoscope in a case with an anterior extending cyst. Exact analysis of the preoperative imaging and selection of appropriate surgical approach are key factors for successful treatment of a quadrigeminal cistern arachnoid cyst.

The optimal duration of cerebrospinal fluid (CSF) drainage after acute aneurysm surgery is unclear. The association between the occurrence of symptomatic vasospasm or late hydrocephalus and the duration of CSF drainage was investigated using multiple logistic analysis in 95 consecutive patients with aneurysmal subarachnoid hemorrhage who underwent surgery within 72 hours after onset. The duration of drainage was significantly related to the occurrence of symptomatic vasospasm and late hydrocephalus. The cut-off values of the duration of drainage for preventing symptomatic vasospasm and late hydrocephalus were 11 days (adjusted odds ratio 0.347, 95% confidence interval 0.135-0.889, p = 0.0274) and 6 days (adjusted odds ratio 4.86, 95% confidence interval 1.46-16.2, p = 0.0099), respectively. Prevention of both symptomatic vasospasm and late hydrocephalus is not possible without additional procedures such as cisternal irrigation using fibrinolytic agents.

A 22-year-old woman presented with a rare case of multiple epidermoid cysts located in the pineal and extracranial regions. Magnetic resonance (MR) imaging showed a lesion in the pineal region as hypointense on the T(1)-weighted image and hyperintense on the T(2)-weighted image, without enhancement. Neuroendoscopic treatment was performed under a diagnosis of pineal cyst. However, the cyst wall was too thick to perforate, although third ventriculostomy was performed. Diffusion-weighted MR imaging demonstrated the lesions in the pineal and extracranial regions as marked hyperintensity. The diagnosis was epidermoid cyst. Subsequently, neuroendoscopic treatment of the pineal epidermoid cyst was performed. Careful preoperative diagnosis of epidermoid cysts based on diffusion-weighted MR imaging is required.

A case of cavernous sinus dural arteriovenous fistula (CS-DAVF) presenting intracerebral venous hemorrhage was reported. An 81-year-old woman was suffered from generalized convulsion accompanied by right conjunctival hyperemia and edema. Computed tomography scan revealed intracerebral hematoma involving right putamen and perifocal edema extraordinarily expanded to inferior part of the right frontal lobe and insular cortex. Cerebral angiography showed a CS-DAVF with retrograde leptomeningeal venous drainage (RLVD) not only to superficial middle cerebral vein but to basal vein of Rosenthal (BVR). Transvenous embolization was performed using mechanically detachable coils and free fibered platinum coils. After embolization, RLVD disappeared and conjunctival symptoms were improved. Hemorrhagic risk of this patient was discussed, based on her angiographical findings. We speculated that deep venous drainage to BVR through uncal vein, in case with poor venous collateral geometry, is one of the risk factor of cerebral hemorrhage.

Carotid endarterectomy (CEA) is the main treatment for atherosclerotic plaque of the cervical internal carotid artery. The surgical anatomy of the carotid arteries was studied in the carotid triangle of 49 cadavers. The carotid bifurcation was located at the level of the lower third of C-3. The superior thyroid artery arose from the anterior wall of the external carotid artery in 70%. of specimens and from the distal portion of the common carotid artery in 30%. The lingual artery arose as a separate trunk between the origins of the superior thyroid and facial arteries in 81% of specimens, with the facial artery from a common trunk in 18%, and with the superior thyroid artery in 1%. The occipital artery arose from the posterior aspect of the external carotid artery above the level of origin of the facial artery in 57% of specimens, between the origins of the facial and lingual arteries in 32%, and below the origin of the lingual artery in 11%. The origin of the occipital artery was positioned low and the distal portion of the occipital artery was crossed by the hypoglossal nerve in 20%. The ascending pharyngeal artery arose from the posterior wall of the external carotid artery above the level of origin of the lingual artery in 66% of specimens, below the origin of the lingual artery in 9%, from the proximal portion of the occipital artery in 19%, from the carotid bifurcation in 2%, and from the internal carotid artery in 2%. The branches of the external carotid artery are the key landmarks for adequate exposure and appropriate placement of cross-clamps on the carotid arteries. It is necessary to understand the surgical anatomy of the carotid arteries to carry out successful removal of plaque and minimize postoperative complications in a bloodless surgical field.

Objective: The surgical anatomy of structures surrounding the anterior clinoid process (ACP) was examined in 39 cadavers to enable safe performance of selective extradural anterior clinoidectomy. Methods: The lateral portion of the optic canal (OC) at the end of the orbit was defined as point A, and the lateral margin of the dural insertion into the superior orbital fissure (SOF) as B. A vertical line from A to the lateral margin of the ACP was assumed to define a crossing, defined as C. Distances between A and B, C and B, and C and A were measured. The length and width of OC and the optic strut were also measured. Results: The mean distances between A and B, C and B, and C and A were 11.8, 8.9 and 6.3 mm, respectively. The mean length and width of OC were 8.9 and 5.7 mm, and those of the optic strut 5.4 and 2.4 mm, respectively. Conclusion: We propose a modified, efficient procedure for selective extradural anterior clinoidectomy, as follows. Drilling is started from the point approximately 9 mm posterior to the lateral margin of the dural insertion into the SOP, and pointed medially in the direction with a right angle to the lateral margin of the ACP. After drilling about 6 mm to reach the lateral border of the OC, unroofing of the OC is carried out to remove the ACP en bloc by fracturing of the optic strut. Using the present procedure, the distance of drilling of the lesser wing of the sphenoid bone is minimized.

Inoculation of a live attenuated herpes simplex virus (HSV) vector, betaH1, into human U87MG glioblastoma cells transplanted into athymic nude mice induced complete regression of tumors. The infected cells underwent histochemically confirmed apoptosis without lymphocyte infiltration after expressing CD30, CD30 ligand (CD30L), tumor necrosis factor (TNF)-alpha, TNF receptor 1 (TNF-R1), FAS, and FAS ligand (FAS-L) with activation of caspases 3 and 8. Induction of the transcripts of these receptors and ligands in inoculated tumors was confirmed by quantitative RT-PCR. To examine the specificity of apoptosis in the transplanted tumor, we inoculated betaH1 into transplanted human lung, breast, gastric, and colon cancer tumors, and similar tumor regression with apoptosis was observed in all tumors. We analyzed the roles of expression of CD30, CD30L, TNF-alpha, TNF-R1, FAS, and FAS-L in the tumors, and found that HSV-induced apoptosis was suppressed by the respective antibodies. These findings indicate that the CD30/CD30L, TNF-alpha/TNF-R1, and FAS/FAS-L interactions resulted in apoptosis and tumor regression in immunocompromised mice. In addition to the death receptor-dependent apoptosis induced by HSV, the expressed ligands and receptors might enhance the susceptibility of tumor cells to cell-mediated cyto-toxicity and augment the activation of tumor-killing lymphocytes in immunocompetent models.

Neuronavigation has become an effective therapeutic modality and is used routinely for intra-axial tumor removal. This retrospective study was conducted to evaluate the clinical impact of neuronavigation and image-guided extensive resection for adult patients with supratentorial malignant astrocytomas. Between 1990 and 2002, 76 adult patients with pathologically confirmed malignant astrocytomas underwent craniotomy and removal of the tumors at the Toyama Medical and Pharmaceutical University Hospital. Of these 76 patients, 42 were treated using neuronavigation with conventional microneurosurgery and the other 34 were treated with conventional microneurosurgery alone. Postoperative early MRI with contrast enhancement was done, and gross total resection was defined as the complete absence of residual tumor. Survival time was analyzed with the Kaplan-Meier method. Prognostic factors were obtained from the Cox proportional hazards model. In univariate analysis, age (65), grade 3, preoperative KPS (/= 80), use of neuronavigation, and gross total resection were significantly associated with longer survival. However, when the data were submitted to multivariate analysis, grade 3, preoperative KPS (/= 80), and gross total resection were independent prognostic factors. The median survival periods of patients receiving gross total resection (vs. partial resection) and neuronavigation (vs. no neuronavigation) were 16 (vs. 9) months and 16 (vs. 10) months, respectively. The percentage of a gross total resection was significantly higher in the neuronavigation group compared to that in the no-navigation group (64.3 % vs. 38.2 %, p0.05). Neurological deterioration occurred in 4 of 42 (9.5 %) and in 6 of 34 (17.6 %) patients after surgery with neuronavigation and surgery without neuronavigation, respectively, although this difference was not statistically significant. Our results showed that neuronavigation increases the radicality in the resection of malignant astrocytomas and is objectively useful for improving survival time.

When adenovirus causes haemorrhagic cystitis in immunocompromised patients, vidarabine is used for its treatment because therapeutic choice is limited. Although vidarabine has been reported to be effective for these patients, its therapeutic basis has not yet been established. Vidarabine dose-dependently inhibited viral replication as assessed by a yield reduction assay. Viral protein synthesis was dose-dependently inhibited by vidarabine but not at all by acyclovir, and the degree of inhibition by vidarabine was different for each of the viral proteins, ranging from 0–40% of the untreated control. These results indicated the specificity and mechanism of action of vidarabine against adenovirus. The concentration of vidarabine and its metabolite in the bladder is suggested to exhibit effective anti-adenoviral activity in suppressing the replication of adenovirus. Thus, our results support vidarabine therapy as a possible candidate for adenovirus-induced haemorrhagic cystitis in immunocompromised patients.

A 48-year-old woman presented with a unique case of isolated third and fourth ventricles associated with neurosarcoidosis, manifesting as upward gaze palsy. She had a past history of surgery for intracranial sarcoid granuloma 10 years previously and placement of a ventriculoperitoneal shunt 3 years later. Magnetic resonance imaging revealed isolated third and fourth ventricles. Endoscopic plasty of the right foramen of Monro, fenestration of the septum pellucidum, and revision of the ventriculoperitoneal shunt were performed. Postoperatively the size of the third and fourth ventricles was reduced, and the upward gaze palsy resolved. Endoscopic treatment is less invasive and effective for the treatment of multiple septum formation in the ventricular system.

A 60-year-old female presented with gait disturbance, urinary incontinence, and recent memory disturbance. Computed tomography and magnetic resonance imaging revealed a partially calcified mass lesion without enhancement in the left caudate head and mild ventriculomegaly. She underwent endoscopic tumor biopsy. The histological diagnosis was astrocytoma grade 2. After the endoscopic procedure she presented with prolonged consciousness disturbance caused by tension pneumocephalus. Tension pneumocephalus is one of the potential complications of neuroendoscopic procedures.

The recent randomized trials, North American Symptomatic Carotid Endarterectomy Trial, European Carotid Surgery Trial, and Asymptomatic Carotid Atherosclerosis Study, have demonstrated the effectiveness of carotid endarterectomy to reduce the incidence of cerebral infarction in patients with symptomatic and asymptomatic high-grade carotid artery stenosis. However, no studies on Japanese patients have been done until now, and recent progress in endovascular stent treatment has been made. The present prospective, multicenter (not randomized) trial, the Japan Carotid Atherosclerosis Study, has started to analyze present practice and propose treatment guidelines for Japanese patients. Here, the protocol and early results of 565 patients registered until the end of January 2004 are presented.

A 79-year-old man presented with an interdural hematoma manifesting as headache. Computed tomography revealed a right parietal intracranial hematoma. Magnetic resonance imaging revealed the hematoma had divided the dura mater into two layers. Craniotomy was performed and a dural pouch containing a solid hematoma was totally removed. Histological examination showed the hematoma had divided the meningeal dura into two layers. This case confirms the location of interdural hematoma.

The relationships between temperature indices and clinical condition on admission or improvement after ventriculoperitoneal (VP) shunting were evaluated in patients with subarachnoid hemorrhage (SAH). Brain temperatures were measured at intervals of 1 cm from the brain surface to the lateral ventricle at shunt operation. Rectal temperature was also measured. The difference between intraventricular and rectal temperatures was correlated with age (p = 0.0486), Glasgow Coma Scale (p = 0.0129), Hunt and Hess grade (p = 0.0101), and improvement score after VP shunting (p = 0.0104). Measurement of brain temperature may predict the outcome of VP shunting in patients with SAH.

We report a case of a huge posterior fossa arachnoid cyst with hydrocephalus. This 15-month-old girl presented with macrocrania and psychomotor retardation. Magnetic resonance (MR) imaging demonstrated ventriculomegaly and a huge cystic lesion in the posterior fossa. A membranectomy was performed microscopically and the patient had a good postoperative course. Magnetic resonance imaging 1 year after the operation revealed adequate reduction in the size of the ventricle and cyst. Progressive macrocrania discontinued and normal development was obtained.

A case with multiple intracranial germinomas involving basal ganglia and corpus callosum is presented. Clinical and sequential neuroradiological studies demonstrated the entire course of multiple tumour development. These findings suggested that the multiple tumours were intracranial metastatic deposits from primary germinoma in the pineal body. A common primary pineal or suprasellar lesion should be carefully ruled out in the cases of germ cell tumours occurring in unusual regions.

OBJECTIVE:We report three patients with symptomatic isolated fourth ventricle after ventriculoperitoneal shunt placement for hydrocephalus associated with ventricular hemorrhage. All three patients were treated successfully with our new method of endoscopic aqueductal stenting under navigating system guidance.METHODS:A therapeutic rigid endoscope was inserted through the thin cerebellar hemisphere, and endoscopic aqueductal stenting was performed via the enlarged fourth ventricle under navigating system guidance.RESULTS:All three patients underwent successful procedures with good outcomes.CONCLUSION:Our method of aqueductal stenting is a reasonable choice for initial treatment of patients with isolated fourth ventricle, and it entails less invasive neurosurgery.

BACKGROUND AND PURPOSE: Hydroxyapatite ceramic microparticles are newly developed embolic materials. The purpose of this study was to evaluate the characteristics, embolic properties of hydroxyapatite ceramic microparticles, and effects of transcatheter embolization from an angiographic standpoint and to histopathologically evaluate the results of animal experimentation. METHODS: After physical evaluation of the characteristics and embolic properties of hydroxyapatite microparticles (100–250 μm in diameter), microcatheter superselective renal artery embolization was performed in rabbits by using this material. Follow-up angiography and histopathologic study of 18 rabbits were performed at different intervals within 24 weeks after embolization. RESULTS: No microcatheter clogging was observed because of excellent visibility of this material in the suspension and because of its excellent navigability due to its nearly oval shape with no “spines.” Angiographic renal arterial devascularization was consistently obtained without unexpected proximal occlusions; follow-up angiography showed persistent occlusion. Histopathologic evaluation confirmed satisfactory embolization of peripheral arteries. Chronic inflammatory cells were observed in several vessels containing hydroxyapatite microparticles. No evidence of angionecrosis, hemorrhage, or extraluminal migration was noted in any sections. CONCLUSION: Hydroxyapatite microparticles are excellent biocompatible embolic materials with good visibility during injection control, capable of producing effective occlusion of the distal arteriocapillary bed.

We have performed rotational DSA for internal carotid artetry (ICA) stenosis and examined cross sectional imaging of the stenosis. Then, we compared the area stenosis rate (ASR) with stenosis rate by NASCET method and with results of duplex carotid ultrasonography. Of consecutive 451 patients who underwent digital subtraction angiography, 28 patients with ICA stenosis were selected for this study. Imaging data were transmitted to a workstation, and three-dimension (3-D) images were prepared, and cross sectional images of the highest-grade stenotic portion were obtained. ASRs were calculated [1-(the area of highest stenotic portion of ICA/the area of distal ICA)] x 100, which were compared with stenosis rates by NASCET method, as well as peak systolic velocity ratios (PSVR) of ICA to common carotid artery (CCA) determined by duplex carotid ultrasonography (USG). Cross sectional images in all patients were made except for restless patients, thereby morphology of the stenosis was feasible and measurements of cross section and diameter were possible. ASR and stenosis rate by NASCET method showed a very high correlation, and ASR was obtained by formula of (12.886 + 1.037 x stenosis rate by NASCET method). In patients with distorted stenosis, the stenosis rate was overestimated by NASECT method. ICA/CCA PSVR could predict stenosis to some extent, and in particular, all the patients with ICA/CCA PSVR of 3.1 or greater were found to have high grade stenosis. However duplex carotid USG failed to detect stenosis in a patient with high-grade stenosis at high position. In conclusion, as to ICA stenosis, 3-D image could show the stenosis precisely, and was considered to be useful as a routine examination.

A 61-year-old woman presented with progressive dementia over a period of 4 months. Computed tomographic (CT) scans and magnetic resonance (MR) imaging showed 2 meningiomas located at the left parasagittal region and the left sphenoid ridge. These tumors had distinct MRI findings; the left parasagittal tumour showed a clear peritumoral CSF space without brain oedema, but the sphenoid ridge tumour was large with marked peritumoral oedema. Total excision of these 2 tumours was attempted with favourable clinical improvement and histological studies revealed meningiomas of different histological types. The left parasagittal tumour was a fibrous meningioma and the left sphenoid ridge tumour was an anaplastic meningioma with typical brain invasion. These tumours showed a MIB-1 staining index of 1% and 30%, respectively. There was also a difference in the immunohistochemical findings for neurofibromin (NF1 product) expression; the left parasagittal tumour expressed neurofibromin but the left sphenoid ridge tumour lacked neurofibromin expression, suggesting an NF1-gene mutation. This case may be a rare example of the simultaneous occurrence of meningiomas with distinct genotypes.

Elongation and bending of the basilar artery are frequently observed in both normal and pathological subjects. However, their mechanism of generation remain unclear. In the present study, we measured basilar arteries in patients and normal subjects using magnetic resonance angiography (MRA) and estimated the relationships between these anatomical changes and some factors such as age, sex and vertebral artery dominance. A total of 510 subjects underwent MRA. Basilar artery length (BAL), bending length (BL), or side of bending of basilar artery was estimated on the plain images including the basilar artery in two groups with and without vertebral union. BAL was longer in males than in females (P = 0.0009) and correlated with age (P0.0001) in the population with vertebral union, while BL did not differ between genders and was not correlated with age in this population. Both BAL and BL were longer in subjects with vertebral artery dominance than in subjects with equivalent-sized vertebral arteries in the population with vertebral union (P0.0001 and P = 0.0005). No difference in the frequency of basilar artery bending was observed between males and females and no correlation was observed between the frequency of basilar artery bending and ages in subjects without vertebral artery union. A significant negative correlation between the side of bending of the basilar artery and dominant side of vertebral arteries was found for group of all patients (P0.0001). BAL growth may mainly depend on aging, and the presence of vertebral artery dominance may contribute to the growth of BAL while BL growth may depend on vertebral artery dominance mainly in the contralateral direction.

Neuronal degeneration within the brainstem has been reported in patients with impaired postural stability. However, the functional significance of these abnormalities is unknown at present. In the present study, we evaluated the relationship between the presence of pontine lacunae and postural stability measured by stabilometry. A total of 209 consecutive patients without neurological signs were divided into three groups according to the territory of lacunae on magnetic resonance imaging: (1) non-lacunar group, (2) pontine lacunar group, and (3) non-pontine lacunar group. Stabilometry was performed and statokinesigram measures including each Romberg quotient were compared among the three groups. Using multivariate analysis, postural stability was found to be disturbed in the pontine lacunar group compared with the other groups. The data of stabilometry in this group were compatible with disturbance of the central controlling system for keeping postural stability. Pontine lacuna is associated with patients with postural instability. This result may be related to the deterioration of the central coordination system for posture and locomotion.

We report a case of an occult intrasacral meningocele. An 11-year-old boy presented with atypical bowel symptoms, severe constipation, and stool incontinence. Magnetic resonance (MR) imaging disclosed an intrasacral cyst containing cerebrospinal fluid (CSF). We diagnosed an occult intrasacral meningocele and performed perforation of the cyst and closure of the fistula. The patient was free from constipation and stool incontinence after the operation. We discuss the clinical features and neuroradiological findings of this rare condition.

A 39-year-old man, who had splenectomy following abdominal trauma 30 years previously, admitted to our hospital with high fever, headache and convulsion on January 8, 2002. Examination of cerebrospinal fluid (CSF) showed pleocytosis up to 10,000 cells/mm3 with polymorphonuclear cells dominant and elevated protein to 330 mg/dl and reduction of glucose to 15 mg/dl. Streptococcus pneumoniae was detected at the culture of CSF and blood. We diagnosed him as having pneumococcal meningitis as overwhelming postsplenectomy infection(OPSI) syndrome. After administration of carbapenem antibiotics, methylprednisolone (1,000 mg) and immunoglobulin, he survived without any complications. Splenectomized patients are likely to suffer from severe infections, such as sepsis and meningitis, which is called OPSI syndrome. The course is rapid, the clinical symptoms are serious, and the prognosis is very poor. It is important for splenectomized patients to receive the vaccine, antibiotic prophylaxis and seek medical attention at the earliest sign of minor infection.

The author describes a case of basilar artery occlusion caused by vertebral artery dissection with vertebral fracture. A 61-year-old man was admitted with neck pain after a traffic accident. His symptoms suddenly deteriorated and cerebral angiography revealed an occlusion of the right vertebral artery, and complete occlusion of the basilar artery. Local-arterial fibrinolysis with urokinase for basilar artery occlusion and angioplasty with the use of a self-expandable stent for the site of the vertebral artery dissection was performed, and the basilar artery was partially recanalized. The patient's symptoms gradually improved. It should be emphasized that in cases of acute cervical spine injury after major trauma, vertebral artery dissection should be considered. Local-arterial fibrinolysis and angioplasty using a self-expandable stent was regarded as a useful treatment for basilar artery occlusion caused by vertebral artery dissection, in the acute stage.

We report an unusual case of dysembryoplastic neuroepithelial tumour (DNT) located in the occipital lobe presenting with only headache. A 31 year old woman presented with headache. She had no history of epilepsy and neurological examination revealed no abnormal findings. Computed tomography (CT) scanning revealed a multilobulated mass lesion with calcification in the right occipital lobe. Magnetic resonance (MR) imaging demonstrated a heterogeneously enhanced mass with hypointense signals on T1- and hyperintense signals on T2-weighted images. The lesion was totally resected and histopathologically diagnosed as DNT. Physicians must bear in mind that DNT may occur in the occipital lobe and present with only mass effect.

p21-Ras, the protein product of the proto-oncogene Ras is overactivated in malignant astrocytomas despite the absence of mutation. It is known that p21-Ras participates in signaling events from membrane tyrosine kinase receptors and a variety of intracellular biochemical pathways to downstream targets. Signal transduction inhibition by targeting against Ras is now thought to be a promising therapeutic strategy for malignant astrocytomas. This study demonstrates that Ras pathway inactivation by a farnesyltransferase inhibitor, B1620, effectively inhibits in vitro and in vivo growth of human astrocytoma cells, although normal human astrocytes (NHA) derived from fetal brain are resistant to B1620. Anti-proliferative effect of B1620 on in vitro growth of astrocytoma cells was examined by MTT assays and soft agar colony formation assay. B1620 inhibited anchorage-dependent growth of six astrocytoma cell lines with a median effective dose (IC50) ranging from 2.0 to 20.7 microM. However, growth of NHA was not significantly affected by B1620 even at the concentration of 100 microM. All astrocytoma cells showed apoptotic figures after Hoechst 33258 staining, when treated for 5 days at each IC50 concentration against B1620. Anchorage-independent growth of these astrocytoma cell lines was inhibited at a much lower concentration than that of anchorage-dependent growth. Daily treatment of U87 xenograft-bearing athymic mice with B1620 at 100 or 50 mg kg(-1) resulted in significant inhibition of tumor growth. A histological study of the B1620-treated tumor tissue showed decreased vascularity with numerous TUNEL-positive apoptotic cells. These results suggest that the mechanism of the growth-inhibitory effect of B1620 is anti-angiogenesis, apoptosis induction and reversion of the transformed phenotype. The potential clinical use of B1620 could be expanded to malignant astrocytomas.

For tumor growth, proteolytic remodeling of the extracellular matrix (ECM) is a key factor. To determine proteolytic activity in human glioma cells, fibrinolytic activity, mRNA expression of fibrinolytic factors, and fibrinolytic inhibitors were studied in human glioma cell lines. The effect of platelet activating factor (PAF), a potent mediator of inflammatory and immune responses, on this fibrinolytic activity was also examined.The fibrinolytic activities of conditioned medium and cell lysates from human glioma cell lines, A172, T98G, U87 and TM1 were studied by fibrin plate zymography. mRNA expression of tissue plasminogen activator (tPA), urokinase-type plasminogen activator (uPA) and plasminogen activator inhibitors (PAI-1, PAI-2) was measured by Northern blot analysis. PAF was added to the medium, and its effects on cell proliferation, fibrinolytic activity, mRNA expression of plasminogens and inhibitors were studied.mRNA expression of plasminogens and inhibitors differed between individual cell lines. Only the medium and cell lysates from A172 cells revealed fibrinolytic activity. A172 cells showed mRNA expression of tPA. PAF at low concentrations, such as 1 nM, stimulated A172 cell proliferation, and high concentrations of PAF inhibited proliferation. PAF stimulated tPA release into the conditioned medium. mRNA expression of tPA was stimulated by low concentrations of PAF and inhibited by high concentrations.The variability of mRNA expression of plasminogen activators (PAs) between different glioma cell lines may indicate that plasminogens and their inhibitors do not directly correlate with brain tumor growth. PAF may be an important factor in the local control of fibrinolytic activity in glioma and its proliferation.

Object: We determined independent variables contributing to the development of late hydrocephalus after subarachnoid hemorrhage (SAH). Methods: A total of 114 consecutive patients who underwent surgery for aneurysms within 72 h after SAH were studied. Thirty-nine patients underwent ventriculoperitoneal shunt (VPS) placement (14 patients within 30 days and 25 patients more than 30 days after onset). Univariate and multivariate analyses were performed to assess relationships among various variables and shunt placement. Results: Three variables were found to be independently associated with VPS patients: (1) the rate of SAH clearance; (2) the duration of external cerebrospinal fluid drainage, and (3) presence of neurological deficits 2 weeks after surgery, which indicates brain damage mainly caused by intraoperative manipulation and cerebral vasospasm. Conclusion: As in previous reports, intraoperative clot removal and duration of external CSF drainage were found to be closely related to the incidence of hydrocephalus. Brain damage due to intraoperative manipulation and cerebral vasospasm is seemed to be involved in the occurrence of late hydrocephalus in this study.

In neuronal cells, myristoylated alanine-rich C kinase substrate (MARCKS), localized to particular areas of the synaptic membrane, is active during brain development. The destination of phosphorylated MARCKS is thought to be the cytoplasm where it is probably inactive. We compared MARCKS phosphorylation in the brains of embryonic, perinatal, and adult rats to determine its possible involvement in neurogenesis.We prepared crude and partially purified extracts from various brain regions of rats aged between embryonic day 14 (E14) and 7 weeks after birth and assayed them for MARCKS phosphorylation by immunochemical methods. The isotypes of protein kinase C (PKC) were immunochemically identified in crude brain extracts from embryonic and postnatal rats. Despite negligible MARCKS phosphorylation, E16 brain extracts contained both MARCKS and PKCgamma, delta, epsilon, and lambda. MARCKS and polypeptides were clearly phosphorylated (49 and 45 kDa, respectively) in brain extracts purified on a DE52 column. Embryonic brain extracts manifested a high-molecular-weight activity capable of suppressing polypeptide phosphorylation. This activity was markedly decreased on the day of birth and almost undetectable in the brains of 9-day-old rats.The embryonic rat brain appears to contain a protein(s) that suppresses the phosphorylation of other proteins including MARCKS. We posit that this inhibitory activity represents a factor(s) that plays a role in the regulation of neurogenesis beginning on the day on which MARCKS appears in the embryonic brain.

Paraventricular fluid cysts have recently been treated by endoscopic fenestration performed from the cysts to the ventricular system. However, correct orientation and safe navigation of the endoscope may be difficult in patients with abnormal anatomy. Endoscopic fenestration from the ventricular system to a cyst was performed through penetration of the septum pellucidum via the anterior horn of the contralateral lateral ventricle. The advantage of this approach is correct orientation and introduction of the endoscope to the periventricular lesion because the usual landmarks can be identified in the normal contralateral lateral ventricle.

We describe a 63-year-old female patient with pure akinesia whose gait was fa cilitated by a handmade converted walking stick. A posterior ventral pallidotomy had been performed, but it did not alleviate symptoms. Her husband made a walking stick with a wire loop at the bottom, perpendicular to the walking direction. When the patient stepped over the loop, the frozen gait was improved. This converted walking stick is easily made and inexpensive. Although the walking stick did not improve the patient's gait radically, use of the converted walking stick effectively improved the patient's daily life because successful treatment of pure akinesia cannot be established.

Etizolam, an anti-anxiety agent which is an antagonist of platelet-activating factor receptors, was administered to patients with chronic subdural hematoma (CSH) after hematoma removal to assess the effectiveness for preventing recurrence compared with control patients not given the drug after surgery. The remaining volumes of subdural hematomas on brain computed tomography were measured approximately 1 month after removal. Volume in the etizolam group (15 patients) was significantly smaller than in the control group (24 patients). Hematoma recurrence was not detected in the etizolam group 3 months after surgery, but occurred in the control group. The difference was significant. Etizolam administration may be useful for the prevention of recurrence of CSH.

Titanium aneurysm clips are superior to cobalt clips in radiological features, biocompatibility, and hypoallergenicity, but the mechanical characteristics are less advantageous. A 56-year-old man was referred to our department due to dizziness and slurred speech. Cerebral angiography unexpectedly disclosed an aneurysm of the right middle cerebral artery. The patient underwent right frontotemporal craniotomy and neck clipping of the aneurysm with a commercially pure titanium clip. After application of the clip, the clip blades crossed and nearly sheared the wall of the aneurysm. The mechanical characteristics of titanium aneurysm clips require careful consideration because of possible clip malfunction.

We reported a case of a 79-year-old male with traumatic vertebral arteriovenous fistula. The patient was admitted with hemorrhagic shock due to arterial bleeding caused by a penetrating injury of the neck. Cervical CT showed free air at the level of the lamina of C1. Injury of the vertebral artery was suspected. The right vertebral angiogram showed an arteriovenous fistula between the V3 portion of the right vertebral artery and the suboccipital venous plexus with retrograde intracranial venous drainage. The patient underwent endovascular treatment of the parent vertebral artery occlusion, which successfully obliterated the arteriovenous fistula.

Objective We have developed a simple and easy modification of the orbitozygomatic approach using one-piece pedunculated craniotomy. This modification prevents atrophy of the temporal muscle, resulting in temporal fossa depression and atrophy of the free bone graft resulting in the occurrence of bone pits along the line of the craniotomy. Methods The key points of this modification are as follows. The scalp flap is elevated in the plane between the superficial and deep layers of the temporal fascia. The temporal muscle is dissected from the temporal plane by performing subperiosteal elevation with intact insertion to the superior temporal line of the temporal muscle, which results in the creation of a subperiosteal tunnel beneath the temporal muscle. The one-piece fronto-orbitozygomatic bone flap is hinged on the temporal muscle. Results After the surgeons had received full training in the procedures and anatomic findings related to this craniotomy in 10 cadaveric heads, surgery was performed for paraclinoid or parasellar tumors in five patients. Although temporary pulsatile exophthalmos occurred after surgery in one patient, no craniotomy-related complications occurred during or after surgery. Because the bone flap is fragile at the frontozygomatic suture, fixation with a small titanium plate was required in three of five patients at the end of the operation. All patients were pleased with the cosmetic results of surgery during a minimum follow-up period of 6 months. Conclusion The modifications described in this article reduce the risk of atrophy of the temporal muscle and improve the cosmetic results without limitation of operative exposure.

A 55-year-old woman presented with fever and a stiff neck due to an intracranial poorly differentiated carcinoma at the right cerebellopontine angle. The patient suffered from typical trigeminal pain and had undergone a removal of the right cerebellopontine angle epidermoid 13 years before at another hospital. On admission, MRI imaging showed a lesion at the right cerebellopontine angle with marked contrast enhancement. Partial removal of the tumor was achieved. A histological examination of the tumor showed a poorly differentiated carcinoma accompanied by typical desquamated tissue of the epidermoid. The patient died 3 months after the operation because of aggressive meningeal carcinomatosis.

No marker that predicts accurately the time of occurrence of cerebral vasospasm due to subarachnoid hemorrhage (SAH) has been reported. In the present study, membrane-bound tissue factor (mTF) and myelin basic protein (MBP) concentrations in cerebrospinal fluid (CSF) were evaluated as a predictor of the time of occurrence of cerebral vasospasm. The mTF and MBP concentrations were measured in the CSF from 28 patients with SAH due to ruptured aneurysm. Serial assays were performed from day 4 to day 14 after SAH. CSF mTF and MBP concentrations from days 5 to 9 correlated with the volume of cerebral infarction due to vasospasm and outcome three months after SAH. From the serial assays, CSF mTF measurements predicted the time of occurrence and severity and irreversibility of symptoms due to vasospasm. In conclusion, CSF mTF is predictive of the occurrence and the recovery of cerebral vasospasm, while CSF MBP is only an indicator of severity of brain damage due to vasospasm.

Background and Purpose — Abnormal ECG changes are frequently observed in patients with subarachnoid hemorrhage (SAH). Recently, evidence has been obtained that right insular cortex mediates sympathetic cardiovascular effects. We therefore assessed the laterality and location of SAH dominance in inducing cardiovascular changes as measured by ECG, blood pressure, and heart rate. Methods — After exclusion of 11 SAH patients who died within 1 month after onset, we studied 118 consecutive patients. Data were obtained from records of blood pressure and pulse on admission. Abnormal ECG changes were determined from ECGs on admission and almost 1 month later. From brain CT scans performed immediately after admission, the amount of SAH in each of the 8 cisterns and fissures was measured semiquantitatively. Results — Twenty-six patients had abnormal changes on admission ECG, while 92 patients did not. Systolic blood pressure, diastolic blood pressure, and the amounts of blood in the left ambient cistern, left suprasellar cistern, quadrigeminal cistern, right ambient cistern, right suprasellar cistern, right sylvian fissure, and the set of all cisterns were significantly greater in the group with ECG change than in the group without ECG change. Multivariate logistic regression analysis with stepwise method indicated that systolic blood pressure >160 mm Hg ( P =0.0006) and the amounts of SAH in the quadrigeminal cistern ( P =0.022) and right sylvian fissure ( P =0.0019) were independently associated with abnormal ECG change. Conclusions — Cardiac consequences are possible in patients with massive right sylvian fissure SAH or when systolic blood pressure is >160 mm Hg.

Microvascular anastomosis has become a general and essential technique in the field of vascular reconstructive surgery. Side-to-side microvascular anastomosis is rarely performed by microsurgeons. Laboratory training models are essential for the development and refinement of microsurgical techniques. A new experimental model of a side-to-side "arterial" anastomosis in the rat internal and external carotid arteries is presented, in which 100 percent patency was accomplished immediately, and was maintained 7 days after anastomosis. This model can provide an experimental and training tool for side-to-side anastomosis of small arteries.