Search

Background and Purpose —MRI studies in patients with atherosclerosis often reveal ill-defined hyperintensity in the pons on T2-weighted images. This pontine hyperintensity (PHI) does not fulfill the criteria of a brain infarct, and its clinical relevance is not established. We examined the frequency, as well as the radiological and clinical correlates, of PHI in poststroke patients. Methods —Three hundred nineteen patients were studied 3 months after supratentorial ischemic stroke with the use of 1.0-T MRI. Brain infarcts, atrophy, white matter hyperintensities, and PHI were registered. The clinical outcome was assessed 3 and 15 months after the stroke. Results —Of the patients, 152 (47.6%) had PHI. The risk factors for stroke did not differ in patients without or with PHI. PHI was related to a higher frequency ( P =0.002) and larger volume ( P P =0.020) and temporal ( P =0.002) atrophy, to central atrophy ( P ≤0.040), and to white matter hyperintensity grade ( P P ≤0.011) or pyramidal tract ( P P ≤0.004). The total volume of brain infarcts (OR 1.22), mean atrophy (OR 3.59), and PHI (OR 3.76) were independent correlates of a poor 15-month outcome. Conclusions —PHI after supratentorial ischemic stroke deserves attention because it relates to poor clinical outcome.

We report a rare case of meningeal melanocytoma in the left frontal region. A 45-year-old man complained of a headache. Magnetic resonance (MR) scanning showed characteristic patterns: a slightly high signal intensity mass in the left frontal region on the T1-weighted image and a low signal intensity on the T2-weighted image. The patient underwent gross total removal of the tumor. The postoperative course was uneventful. After two years, there was a small local recurrence. The histological finding of the tumor showed meningeal melanocytoma. To our knowledge, this is the second published report of a meningeal melanocytoma in the supratentorial region.

An exact surgical approach to cavernous malformations, in particular those located in areas of critical brain function, is important for their microsurgical resection without putting too much strain on the patient. During a two-year period, 29 cavernoma resections were performed. Stereotactic guidance was performed in 16 cases (55.2%). Nine cavernomas located in the supratentorial region were resected using the stereotactic operating microscope "MKM", which represents 21.6% of a total of 51 MKM-navigated operations; in one further case system referencing failed. The experience gathered with this frameless stereotactic system is compared to a retrospective analysis of 5 frame-based stereotactic cavernoma localizations. Frameless stereotactic localization has been shown to be sufficiently accurate but more advantageous than frame-based techniques in terms of utility, ease of integration, and detailed image-guided anatomical information. Software improvements have resulted in a high stability of the frameless stereotactic system.

Other than hamartomatous enlargement of the cerebellum as in Lhermitte-Duclos syndrome, diffuse enlargement of the cerebellum is not clearly described. We report four patients (ages 9 months to 2 years) with diffusely enlarged cerebelli as identified by measurement of the cerebellum and comparison to age appropriate normal values. The cerebellar measurements were determined in absolute numbers and expressed as ratios of cerebellum to whole brain and supratentorial brain. The clinical features of these four children (3 boys, 1 girl) consistently include global developmental delay, tone abnormalities, preserved reflexes, delayed or abnormal maturation of the visual system (oculomotor apraxia), and deficient or delayed myelination of cerebral white matter. The etiology of the macrocerebellum is unknown but we propose that the cerebellum is responding to the elaboration of growth factors intended to augment the slow development of cerebral structures. Regardless of the etiology, the finding of a macrocerebellum appears to allow the clinician to predict the clinical features of the patient and probably represents a marker for disturbed cerebral development. (J Child Neurol 1997;12:365-368).

In this study factors are analyzed that may potentially influence the site of failure in pediatric medulloblastoma. Patient-related, disease-related, and treatment-related variables are analyzed with a special focus on radiotherapy time-dose and technical factors.Eighty-six children and adolescents with a diagnosis of medulloblastoma were treated in Switzerland during the period 1972-1991. Postoperative megavoltage radiotherapy was delivered to all patients. Simulation and portal films of the whole-brain irradiation (WBI) fields were retrospectively reviewed in 77 patients. The distance from the field margin to the cribiform plate and to the floor of the temporal fossa was carefully assessed and correlated with supratentorial failure-free survival. In 19 children the spine was treated with high-energy electron beams, the remainder with megavoltage photons. Simulation and port films of the posterior fossa fields were also reviewed in 72 patients. The field size and the field limits were evaluated and correlated with posterior fossa failure-free survival.In 36 patients (47%) the WBI margins were judged to miss the inferior portion of the frontal and temporal lobes. Twelve patients failed in the supratentorial region and 9 of these patients belonged to the group of 36 children in whom the inferior portion of the brain had been underdosed. On multivariate analysis only field correctness was retained as being significantly correlated with supratentorial failure-free survival (p = 0.049). Neither the total dose to the spinal theca nor the treatment technique (electron vs. photon beams) were significantly correlated with outcome. Posterior fossa failure-free survival was not influenced by total dose, overall treatment time, field size, or field margin correctness. Overall survival was not influenced by any of the radiotherapy-related technical factors.A correlation between WBI field correctness and supratentorial failure-free survival was observed. Treatment protocols should be considered that limit supratentorial irradiation mainly to subsites at highest risk of relapse. Optimized conformal therapy or proton beam therapy may help to reach this goal. Treating the spine with electron beams was not deletereous. A significant correlation between local control and other technical factors was not observed, including those relating to posterior fossa treatment. The use of small conformal tumor bed boost fields may be prefered to the larger posterior fossa fields usually considered as the standard treatment approach.

Rhabdoid meningioma (RM) is a histological subtype of meningioma, associated with aggressive behaviour, characterized by patches or sheets of rhabdoid cells [2, 3, 4], similar to renal and extra-renal rhabdoid tumours [1, 7] and atypical teratoid/rhabdoid tumour (AT/RT) [6]. A RM with expression of desmin in the tentorium of a 12-year-old female, is described. To the best of our knowledge, this is the first case in a Turner syndrome patient. Clinical history consisted of several months of headache and right arm weakness. Neurological examination revealed right-sided hypotonia and hypostenia, tremor, imbalance, and ataxic gait. Physical examination showed short stature and delayed sexual development. On the basis of karyotype analysis, Turner syndrome was diagnosed. Computed tomography demonstrated a hyperdense mass in close relationship with the right cerebellar hemisphere, compressing the fourth ventricle. Magnetic resonance imaging (MRI) (Fig. 1a) demonstrated a T1 isointense, T2 hypointense tumour of the tentorium with extra-axial extension, both caudally and cranially. A ‘dural tail’ was seen medially. Necrotic portions were persistently hypointense after gadolinium administration. No brain or spinal metastasis were observed. The patient underwent a parieto-occipital craniotomy. The tumour was located in the posterior fossa, arising from the dura of the inferior surface of the tentorium, and extending into the supratentorial region. As the tumour was attached to the transverse sinus, only a subtotal resection was achievable. A minimal residual tumour, not demonstrated by post-operative neuroimaging, was left. Abdominal ultrasonography and chest X-ray were normal. After diagnosis the patient received local radiotherapy and hydroxyurea chemotherapy. MRI at 20 months was negative. Microscopic examination disclosed a highly cellular tumour entirely composed of sheets of large oval cells with eosinophilic cytoplasm, containing globular eosinophilic inclusions, and eccentric nuclei. Mitotic index was high (12/10 high-power field) (Fig. 1b). Multiple foci of necrosis were seen. Meningothelial lobules, whorls, and psammoma bodies were absent. Brain invasion was not observed. Tumour cells showed strong immunoreactivity for vimentin and focal membrane staining for epithelial membrane antigen (EMA) (Fig. 1c); the inclusions were immunoreactive for desmin (Fig. 1d). Tumour cells were negative for smooth muscle actin, muscle specific actin, MyoD1, myogenin, S-100 protein, and CD34. MIB1 labelling index was 15%. The coding sequences of hSNF5/INI1 and NF2 genes were screened by single-strand conformation polymorphism. The microsatellite markers (D22S1685D22S1553) on 22q11.23, near the hSNF5/INI1 locus, were analysed. No aberrant migration pattern of INI1 gene or loss of heterozygosity of INI1 locus were found. A deletion of exon 9 of the NF2 gene was detected. The first two authors contributed equally.

We studied 34 patients with presumed vascular dementia (20 men and 14 women, average: 69.86) on a 0.2T MR system. T2-weighted on axial images and T1-weighted midsaggital images were obtained. The volumes of the subarachnoid and ventricular spaces, brain parenchyma and T2 signal-alteration areas were calculated using a semiautomated method. Volumes of supratentorial contents were normalised to relative values. We also calculated the ratio between the area of corpus callosum (CC) and the volume of supratentorial brain. Cognitive function was evaluated using a battery of neuropsychological tests. MRI showed an increase in size of the sulci and ventricle volumes correlated with parenchymal atrophy (P

To evaluate whether hemispheric lesion distribution in multiple sclerosis is related to the uneven interhemispheric localisation of cerebral function, a 10 item self administered questionnaire evaluating hand preference and supratentorial brain MRI was obtained in 23 patients with clinically definite multiple sclerosis. The mean degree of hand preference was +74 (range -86 to +100). The median lesion volumes were 7275 (range 1045-22 440) mm(3) for the left hemisphere and 5385 (range 1010-19 490) mm(3) for the right hemisphere. The degree of hand preference correlated with the index of interhemispheric lesion distribution (P = 0.02). The data suggest that local events, possibly related to specialisation of hemispheric function, might be responsible for the increased vulnerability of the dominant hemisphere to the pathological process of multiple sclerosis.

The patient had a shunt placed for obstructive hydrocephalus. An endoscopic biopsy of the intraventricular and septal mass was performed which showed findings consistent with a cavernous angioma (Fig. 1). Intracranial vascular malformations are divided into four groups: (i) capillary telangiectasia, (ii) cavernous angioma, (iii) arteriovenous malformation, and (iv) venous malformation. Cavernous angiomas comprise 5% to 13% of all vascular malformations and occur in about 0.5% of the general population. Cerebral cavernous angiomas occur sporadically and in a familial form. Familial cavernous angiomas account for up to 54% of cerebral cavernous angiomas. The most frequent symptoms are seizures, gross intracranial hemorrhages, focal neurological deficits, and migraine-like headaches. The prospective annualized hemorrhage rate calculated on a per-patient basis is 1.6% to 3.1%. Intracranial cavernomas are commonly located in the supratentorial region, brain stem, basal ganglia, and cerebellar hemisphere. On the basis of MRI, four

Edited by Anil Nanda, 1st Edition, 2012. Published by Thieme Medical Publishers, Inc., New York, pp 252 (hardcover). (Foreward by Peter J Jannetta). ISBN: 978-1588906632 Having authored one of the chapters, we have been familiar with this project during its evolution. This well-organized book fills a niche as a comprehensive but concise reference or vade mecum dedicated to the unique neuroanatomical compartment of the posterior fossa. It is well known to neurosurgeons that the range of disorders that include trauma, neoplastic lesions and vascular pathologies are managed differently by virtue of involving the infratentorial region, in contrast to analogous pathologies of the supratentorial region. In addition, there are …

We present a rare case of dysembryoplastic neuroepithelial tumor, a rare benign glioneuronal tumor of the central nervous system. It generally occurs in the supratentorial region and the temporal cerebral cortex in children and young adults. The most common presentation is epilepsy. The supratentorial tumor without any signs of mass effect or peritumoral edema is the conventionally accepted diagnostic criteria. In this case of a 19-year-old male with intractable epilepsy, atypical features such as the location of the tumor and the presence of mass effect and peritumoral edema made imaging diagnosis difficult. Diagnosis was confirmed through histopathology. Due to its recent discovery and relatively rare occurrence it is important for radiologists to recognize this disease entity.

We studied the frequency of supratentorial brain infarction as the cause of late-onset epilepsy in 680 patients with a first seizure after the age of 20, registered on an epilepsy register: 65 (10%) had seizures following a symptomatic supratentorial brain infarct. Brain infarction as the presumed cause of epilepsy was related to age at first seizure. A first seizure occurred within one year after brain infarction in 62%, and later than two years in 19%. Eight of 14 patients (57%) with an early seizure (or = 2 weeks), and 28 of 41 patients (68%) with a first seizure later than two weeks post-stroke had seizure recurrences despite anti-epileptic treatment. Of 38 patients who underwent computed tomography head scan (CT), 32 (84%) had a cortical infarct, whereas six (16%) had one or more lacunar infarcts. This may indicate that lacunar infarction may be associated with post-stroke epilepsy. Using a detailed topographic brain atlas to localize the cortical infarcts, no 'specific epileptogenic' gyri could be identified. What factors predict future epilepsy in stroke patients need to be studied in prospective series of well-defined stroke subgroups.

Between January 1989 and June 1991, 40 ultrasound-guided biopsies of supratentorial brain lesions exceeding 15 mm in diameter were performed. The apparatus used was Berger's neurobiopsy set, intraoperative 5 = MHz transducer, and a B-mode scanner. In 38 cases (95%) the procedure provided a histological diagnosis at the first attempt; in two patients, early in the present series, biopsy was repeated by computed tomography-guided technique due to insufficient samples. Operative mortality was zero and there were no septic complications. Clinical symptoms were stationary after the procedure in 34 cases; two cases temporarily worsened due to postbiopsy edema and subcortical hemorrhage, respectively; and four other cases showed an improvement as a result of evacuation of neoplastic cysts. Histologically, there were 24 primary malignant tumors, eight low-grade glial tumors, five metastatic tumors, two abscesses, and one lymphoma. The ultrasound method for brain lesion biopsy was found to be a simple, quick, and low-cost method that gave reliable results. It is indicated for supratentorial lesions over 15 mm in diameter that do not demand absolute anatomical accuracy.

Dear Editor, We read with interest the recent publication “The clinical spectrum of Blake’s pouch cyst: report of six illustrative cases” by EMJ Cornips et al. [1]. In regard to case one, illustrated with figure 1. The image d, showing the postmortem findings, demonstrates both the supraand infratentorial regions. In the posterior fossa, the hemorrhage in the Blake’s pouch cyst is evident. But on the other hand, in the supratentorial region, the occipital lobes are covered by a yellowish material. We think that it could correspond to a purulent process rather than “a massive cerebral necrosis”; we also think that over the cerebellum there is also purulent material.

In a well-defined prospective series of 247 patients with a first-ever supratentorial brain infarct, 15 patients (6%; 95% confidence interval 3-9%) had a large striatocapsular infarct. Twelve (80%) had signs of cortical dysfunction, whereas risk factor profile, frequency of significant carotid stenosis, and frequency of potential cardioembolic sources did not differ between patients with striatocapsular and those with cortical infarction. However, patients with striatocapsular infarction more frequently had potential cardioembolic source and significant carotid stenosis than patients with lacunar infarction. Our findings show that large striatocapsular infarcts differ from lacunar infarcts with regard to both presenting signs and symptoms, and pathogenesis, whereas they resemble infarcts involving the cortex. Such patients should therefore be managed and treated as patients with cortical infarction.

This paper summarises the role and specificity of the most common used techniques for brain tumour imaging. When a supratentorial brain neoplasm is suspected, investigations are directed towards certain questions including: confirmation of the presence of an intracranial structural abnormality; determination of its possible nature; prediction of its degree of malignancy; assesment of extent and location relative to critical structures; prediction of its internal structure and probable consistency and evaluation and response to treatment. It is appreciated that the majority of these inter-related questions can be answered by computed tomography or magnetic resonance imaging. Ultrasound continues to have a role in the young patients while plain skull radiographs, conventional radionuclide studies and pneumoencepahalography no longer have a role to play except in rare circumstances. 57 refs., 18 figs.

Brain tumors represent the second most common malignancy in childhood. Of 887 childhood brain tumors identified by the SEER (Surveilance, Epidemiology, and End Results) registries, 57% were astrocytomas of low or high grade, supratentorial astrocytomas, cerebellar astrocytomas, or brainstem gliomas. Astrocytomas thus comprised the largest histological grouping in the SEER registry [26]. Most cerebellar astrocytomas and some benign supratentorial gliomas are adequately treated with surgical resection alone. Treatment of high-grade supratentorial astrocytomas, brainstem gliomas, and chiasmatic gliomas require, in addition to operation, radiation therapy. Furthermore, chemotherapy and immunotherapy are now being used more frequently, especially in the very young. This chapter discusses the current management of childhood astrocytomas occurring in the supratentorial region, anterior visual pathways, brainstream, cerebellum, and spinal cord.

• The clinical data and computed tomographic findings of 64 patients with solitary supratentorial brain lesions were presented to two panels of six experienced clinicians. The diagnoses predicted by these clinicians were compared with each other (interobserver variation) and with the definite diagnosis, which in almost all cases was based on histologic examination of the involved tissue (validity of predicted diagnosis). The interobserver agreement was only moderate. The predicted diagnoses agreed with the definite diagnoses in only 57% of cases. A high number of errors were made in distinguishing between high-grade and low-grade glioma and between high-grade glioma and cerebral metastasis, and in the detection of primary cerebral lymphoma. Possible implications of these findings for clinical practice are discussed.

The prognosis of 560 patients with a clinical and CT diagnosis of intrinsic supratentorial brain tumour was examined retrospectively at the Department of Neurosciences, Walton Hospital, Liverpool, England.

We reviewed CTs from 47 patients with 48 spontaneous, supratentorial brain hemorrhages to determine the effect of ventricular blood on outcome. We correlated volumetric analysis of the parenchymal (P) and ventricular (V) blood, as well as other clinical and CT features, with clinical outcome in a statistical analysis. Hemorrhages were located in putamen 20/48 (42%), thalamus 13/48 (27%), lobar 9/48 (19%), caudate 3/48 (6%), and miscellaneous locations 3/48 (6%). Outcome in putaminal hemorrhages was highly correlated with the total (P+V) and P blood volumes, whereas the V blood was less important. For thalamic hemorrhages, outcome correlated more highly with the V and P+V volumes than with the P portion. Outcome for ail hemorrhages was significantly correlated, in descending order of importance, with the severity of the initial neurologic deficit, P+V blood, hydrocephalus, the number of ventricles containing blood, P, V, and blood in the 4th ventricle. In general patients with more than 20 cc of V blood did poorly. Although hydrocephalus was associated with poor outcome, ventricular drainage did not benefit 8 of 9 patients.

One hundred and thirty EEGs were analysed from 113 patients with acute secondary traumatic midbrain and bulbar brain syndromes. The EEG pattern was related to the stage of the midbrain syndrome caused by supratentorial brain shift. A decrease in the number of different EEG patterns was associated with increasing intracranial pressure. Unfavourable prognosis was indicated by the disappearance of sleep or sleep-like activities, alternating pattern and loss of reactivity. Lateralization by the EEG proved to be superior to clinical findings in full stages of the midbrain syndrome. EEG abnormalities due to the herniation itself interfered with EEG changes due to secondary circulatory, respiratory and metabolic encephalopathies. In such cases, the above mentioned regularities were blurred.

✓ A retrospective analysis of 21 cases of primary central nervous system (CNS) lymphoma is reported. All patients presented with a solitary mass in the supratentorial region. None had previously received immunosuppressive therapy. Neuroradiological studies included technetium-99m-pertechnetate brain scanning in eight cases, cerebral arteriography in all 21 cases, and computerized tomography (CT) in 14 cases. The characteristic features were increased uptake in brain scans, mass effect in arteriograms, and marked contrast enhancement on CT scans. Abnormal tumor vessels were occasionally seen on arteriography, and subtraction films were usually required to appreciate tumor stain. All patients underwent craniotomy, and histological studies of the tumors showed a diffuse type of lymphoma in all cases. Immunoglobulin testing was performed in 19 cases and a monoclonal spike was verified in 10, suggesting a B cell origin. All patients were followed until their death except one who was still alive 12 months from onset of symptoms. Therapy included subtotal resection in all 21 cases, whole-brain irradiation in six cases, chemotherapy in two cases, and a combination of whole-brain irradiation and chemotherapy in nine cases. Three different forms of chemotherapy were used. The results suggest that chemotherapy is an important addition to subtotal resection and whole-brain irradiation in the treatment of primary CNS lymphoma.

Two children, below 15 years of age, developed brain abscesses after esophageal dilation. They were among 40 children treated for supratentorial brain abscesses during the past 10 years. Pus culture of one of the abscesses was peptostreptococcus, which is a common oropharyngeal flora. Clinicians should be aware of this complication since the prognosis is usually satisfactory after prompt treatment.

大脳虚血により小脳の脳血流自動調節能 (以下, 自動能) も障害される.これに交感神経がどのように関与するかを検討した.脳虚血は, 高血圧自然発症ラットの両側総頸動脈結紮により作製した.脳血流は水素クリアランス法で測定し, 脱血による血圧下降時の自動能を観察した.脳虚血作製前では大脳小脳の自動能は保たれ, α及びβ遮断薬の影響をうけなかった.脳虚血時には, 大脳の自動能は高度に障害され, いずれの遮断薬群においても30%の血圧下降により大脳血流は前値の約20%まで低下した.一方, 小脳では, 15%及び30%降圧に対し, β遮断薬群では小脳血流が降圧前値の75%, 62%に低下し, 自動能が消失したのに比し, α遮断薬群では90%, 87%と脳血流の低下はほとんどみられず, 自動能がよく保たれた.これらの事より大脳虚血時の小脳における自動能障害には, α受容体の関与が示唆された.

In 64 cases suffering from severe head injury (Glasgow coma scale: less than seven- the auditory brainstem responses (FARs) recorded at the vertex, which are thought to be volumet conducted far-field potentials reflecting the sequential electrical activities of the auditory afferen) system in the brainstem, were recorded in the neurosurgical intensive care room immediately after admission. The alterations in the responses were compared with the types of primary injury, neurological signs., CT findings and outcome following treatment. Based on the results obtained, it is concluded that the FAR is a useful indicator for predicting the effects of treatment on brainstem damage in patients with severe head injury, and that it provides more reliable information about the function of the brainstem than the neurological signs or CT findings. Moreover, it also offers a diagnostic method for primary brainstem injury. Three cases or primary brainstem injury without lesions in the supratentorial region were diagnosed by means of combined CT and FAR recording.

Under treatment of peritumoural brain oedema with 6-methyl-prednisolone, in most cases there are no significant density changes to be seen on the CT although there is undoubted clinical improvement. In order to get data for an optimal timing of pre-operative treatment with steroids we had to prove the effect of 6-methyl-prednisolone (Urbason, Hoechst) with intermittent measurements of the so-called CT "Region of interest" in always the same parts of the perifocal brain oedema for seven days pre-operatively. This study was carried out in ten patients with solitary supratentorial brain tumours. CT measurements on the first day without medication, continued with an initial dosage of 1000 mg Urbason, followed by 3 X 40 mg daily during the second to the fifth day, and finally on the seventh day after the steroid was stopped. In all cases we found increasing attenuation coefficients due to decreasing oedema with a peak on the fourth and fifth days.

The EEGs of adult patients with suspected supratentorial brain lesions were recorded on paper and on magnetic tape, using a small computer. The spectra of 16 channels were computed on a 40 sec sample. For each channel, a ratio of the type (delta + theta)/(alpha + beta) was computed and displayed on the computer terminal, a measure of the asymmetry in slow wave activity between homologous areas of the head was also displayed. This display is called a canonogram. It is believed to be a meaningful representation of the important characteristics of the EEG in the presence of supratentorial lesions. In order to assess the clinical value of the canonogram, the presumed localization of the lesion obtained from the interpretation of the traditional EEG and from that of the canonogram were compared to the known location of the lesion is a group of 87 subjects. The comparison was made quantitative by the use of a structured report encoding the traditional interpretation and that of the canonogram as well as the reference data (unequivocal surgical, radiological and clinical localizing evidence). The results varied among the anatomical regions: whereas in the frontal and occipital regions the EEG was slightly more accurate than the canonogram, both methods were similar in the temporal areas and the canonogram seemed more accurate in the centro-parietal regions. An attempt was made to interpret these differences. Furthermore, three readers read the cononograms and gave very consistent interpretations. These results show the reliability and value of this simple computer display for the particular type of EEG studied.

Summary One hundred and sixty-five EEGs were analysed from 140 patients in postraumatic coma with secondary traumatic midbrain and bulbar syndrome. The EEG-pattern was related to the stage of midbrain or bulbar syndrome caused by supratentorial brain shift. There was a close relation between EEG-pattern and the grade of rostro-caudal impairment. A decrease in the number of different EEG-patterns was associated with increasing intra-cranial pressure. An unfavourable state of coma was indicated by the disappearance of sleep or sleep-like activities, alternating pattern and loss of reactivity. In deep stages of coma the neurological examination reveals no lateralizing signs at all. The EEG gives the only hint to a local cerebral lesion. EEG-abnormalities due to the herniation itself interferred with the EEG-changes due to secondary circulatory, respiratory and metabolic encephalopathies. In such cases the above mentioned regularities were blurred.

During experimental supratentorial epidural compression of the brain, cerebrospinal fluid (CSF) pressure and pressure-volume index (PVI) were measured in the supra- and infratentorial compartments of the craniospinal axis in anesthetized ventilated cats. A transtentorial gradient of CSF pressure developed when CSF pressure in the lateral ventricle exceeded 20 mm Hg at balloon volumes of 0.4 to 1.2 ml. The shapes of both the pressure vs. volume and the pressure gradient vs. volume curves were exponential. PVI in the supratentorial compartment was lowered more rapidly as brain compression advanced than PVI in the infratentorial compartment. An index was calculated to represent the relative resistance to the flow of CSF across the tentorial hiatus during supratentorial brain compression. This revealed different resistances to the flow of CSF in the cephalic and caudal directions. A hypothesis concerning the hydrodynamic aspects of the development of tentorial herniation is presented.

In a recent retrospective study (Ringelstein et al., 1985), we analyzed the patterns of supratentorial brain infarctions on computed tomography (CT) in 421 patients and related these findings to the associated clinical and angiological data

W E HAVE seen four unusual cases of benign, solitary, supratentorial brain cysts, none of which communicated with the subarachnoid or ventricular systems. Until Starkman and Brown described the clinical entity of supratentorial arachnoidal cysts 17 in 1958, most of these lesions had been included in discussions of porencephaly, pseudoporencephaly, or cystic hygroma? All of the cysts in our series behaved as intracranial masses, were associated with progressive neurological dysfunction, and were diagnosed preoperatively as brain tumors.

One or more types of hallucinations were experienced by 96 out of a group of 458 cases of supratentorial brain tumor. Formed auditory hallucinations were related predominantly to temporal lobe lesions, though the frontal and parietal were also involved. Unformed auditory hallucinations were related predominantly to frontal and temporal lesions, though all the lobes were involved as well as midline lesions notably the pituitary: in lobe lesions the hallucinations were usually on the side of the lesion. Although pure occipital lobe lesions gave rise to only visual hallucinations, either formed or unformed or xanthopsia, formed and unformed visual hallucinations were related to lesions in all the lobes of the brain in almost equal distribution, the temporal showing a slight predominance. Xanthopsia seemed related to occipital lobe lesions. Olfactory hallucinations were related to lobe lesions throughout the entire brain, though mainly to the temporal, with frontal and parietal next in descending order. Tacti...

An investigation has been made on the occurrence of sharp waves, spikes and fast activity (18–28 c/sec.) in 100 supratentorial brain tumours. 1. 1. Random localized sharp waves were observed in 23 cases, most frequently with astrocytomas (47 per cent), and less often with meningeomas (22 per cent) and glioblastomas (17 per cent). In 20 of the cases sharp waves were recorded from the same region as the tumour and in 3 from an adjacent region. There was no correlation between the incidence of clinical epilepsy and sharp waves. Of the 57 patients with epilepsy, sharp waves were demonstrated in 13 cases, while in 10 other cases these potentials were seen without the patients having any evidence of epilepsy. Focal sharp waves are of definite localizing value in brain tumours. 2. 2. Random or rhythmic spikes occurred in 4 patients. They were recorded from the region of the tumour in only one case. 3. 3. Fast activity was found in 26 patients. It was most prominent in the frontal and parietal regions. In 6 cases it was recorded from the side of the tumour, in 8 from the opposite side and in 12 it was equally prominent on both sides. There was no difference in the occurrence of fast activity in meningeomas, astrocytomas and glioblastomas. No correlation was found between the occurrence of fast activity and epilepsy. Fast activity from the side opposite to that of the tumour might in some cases have been due to barbiturate medication; in other cases no explanation could be given for its appearance on the opposite hemisphere. Fast activity arising from the side of the tumour may be of the same nature as focal sharp waves and focal spikes. Fast activity has no localizing value in supratentorial tumours. 4. 4. “Sharp activity”, most probably due to fast activity superimposed upon slower waves, was noted in 20 patients: in 6 cases only on the side of the lesion, in 6 on the opposite side and in 8 from both hemispheres. This kind of activity has not any more localizing value than the slow component alone.

✓ Hemangioblastomas are rarely seen in the supratentorial region, especially in childhood. The case of a 10-year-old boy with left parieto-occipital cystic hemangioblastoma is reported. The neoplasm was not attached to the dura, nor was it associated with von Hippel-Lindau syndrome or with erythrocythemia. Cerebral angiography showed no evidence of a vascularized tumor, whereas computerized tomography gave more accurate information. The gross and microscopic appearance of the lesion is described, and a review of similar cases previously reported in the literature is presented.

Five selected cases of large supratentorial brain abscesses, diagnosed by computerized tomography (CT) and successfully treated by aspiration alone, are reported. The two main techniques of treating brain abscesses are discussed briefly.

To assess the effect of supratentorial cerebral ischemia on infratentorial brain function, changes in regional cerebellar blood flow (rCeBF), after right carotid occlusion for 4 hours, were studied in 30 mongolian gerbils. The regional cerebral blood flow (rCBF) in the occluded cerebral hemisphere and rCeBF in both cerebellar hemispheres were measured simultaneously by hydrogen clearance methods. Before carotid occlusion, rCBF was 0.44 +/- 0.07 ml/g brain/min, and rCeBF in the left and right cerebellar hemispheres was 0.37 +/- 0.09 and 0.40 +/- 0.09 ml/g brain/min, respectively. After carotid occlusion, rCBF decreased in all animals showing levels of above 0.20 ml/g brain/min in 14 (group A), between 0.10 and 0.19 ml/g brain/min in 7 (group B) and below 0.10 ml/g brain/min in 9 (group C). rCeBF exhibited no changes in group A and a mild reduction in group B after carotid occlusion. In group C, rCeBF was significantly reduced 30 min after carotid occlusion in the left cerebellar hemisphere followed subsequently by bilateral reduction. In groups B and C, supratentorial brain edema was observed 4 hours after occlusion, but the degree of edema was moderate. The results of the present study suggest that depression of infratentorial brain function may occur after supratentorial local cerebral ischemia, presumably due to diaschisis.

Eleven cases of traumatic intracerebellar hemorrhage caused by severe head injury were presented and examined for their neurological signs, associated computed tomography (CT) findings and their outcome. These cases were divided into two types. The first is an acute type, which showed intracerebellar hemorrhage on the initial CT, and the second is a delayed type, which showed a hemorrhage on a subsequent CT without any findings in the posterior fossa in the initial CT scanning. The state of consciousness on admission of these patients was 8 or less by the Glasgow Coma Scale except for one case. Signs of brain stem injury were frequently seen on admission, such as absence of oculocephalic reflex, respiratory disturbance, and conjugate deviation of the eyes. Cerebellar signs were not usually observed. Nine out of 11 patients died and the Glasgow Outcome Scales of the two surviving cases were severe disability and persistent vegetative state. Associated CT findings of supratentorial region were observed in all cases of the acute type and three cases (75%) of the delayed type. There was not much difference in the neurological signs and the associated CT findings between the acute type and the delayed type. These results suggest that a strong impact acted on a supratentorial region as well as on the posterior fossa. With the introduction of CT scan, it has become much easier to diagnose this pathology. These cases suggest that a prompt evacuation of the hematoma or decompression of the posterior fossa should be attempted to yield satisfactory clinical results.

A historical review of the literature of brain abscess is made and an examination of the universally high mortality and morbidity figures achieved in the past, mainly with conventional burrhole aspiration. A series of 50 cases of supratentorial brain abscess treated over a period of 12 years by immediate primary excision, is presented with discussion. Mortality rate, including patients in coma on admission, was 6%. Morbidity in survivors was correspondingly low.

✓ A rare case of multiple primary hydatid cysts of the brain is reported in a 9-year-old girl. There were five cysts, occupying most of the right supratentorial region. The biggest cyst measured 9 cm across, while the smallest one was 4.5 cm in diameter. The diagnosis was based on computerized tomography findings. The patient did not have any evidence of hydatid disease elsewhere in the body. The delivery of all the cysts resulted in the dramatic neurological recovery of this patient.

After a description of the topographic anatomy, the different approaches to the tentorial notch and the details of technique are illustrated by a few examples. The pterional approach permits surgical treatment of lesions in the supratentorial region of the anterior and middle third of the tentorial opening. Any approach to the infratentorial region can be enlarged and improved by incising and stitching back the free margin of the tentorium. The medial occipital approach is appropriate for space-occupying lesions situated medially in the ascending portion, that is in the posterior third of the free margin of the tentorium. Infratentorial tumours in the cerebello-pontine angle and in the prepontine region, with extension into the tentorial notch, are best treated through the lateral suboccipital approach. A subfrontal infrachiasmatic procedure is indicated in the case of suprasellar lesions with parasellar extension into the tentorial notch, if the anatomy of the optic chiasm allows it. The location of any particular lesion may call for a combination of different approaches.

When active cerebral vasodilatation occurs during progressive supratentorial brain compression it causes increasingly large rises in ICP. It has been suggested that such episodes of intracranial hypertension produced by vasodilatation may produce neurological deterioration either through cerebral ischaemia consequent on a fall in cerebral perfusion pressure (1) or by promoting tentorial herniation of the brain (2).This investigation was directed towards this problem.

✓ A retrospective survey of 41 patients with unbiopsied thalamic, pontine, and medullary tumors treated with radiation therapy demonstrated 30% to 40% 3-year survival, with seven long-term survivors. Eleven of the 12 patients surviving over 3 years have essentially normal neurological function. Of seven patients in whom histological diagnoses were eventually obtained, four proved to have glioblastomas and three low-grade astrocytomas. Autopsy revealed that all glioblastomatous tumors extended beyond the treatment field; this suggested that larger volumes, perhaps the whole brain, should be irradiated. High doses (at least 5000 rads) should be used since the 3-year survival among those receiving such doses was 45%.

Although the infratentorial brain volume is only one tenth of that in the supratentorial region, some 55% of all intracranial tumors in children are found in the posterior cranial fossa (Table 1). This is in sharp contrast to the situation in adults where most tumors occur in the larger volume of the supratentorial region and only 10% arise in the posterior fossa.

Children with tumors of the posterior fossa are quite often referred to a radiotherapy department for some phase of management. Only a very few highly specialized institutions, however, have enough cases to permit evaluation of the effect of treatment and observation of the full course of the disease. As is well known, two features distinguish brain tumors of children from those of adults. The most significant is the higher percentage of gliomas in children. Figures range from 60 to 80 per cent for children and from about 40 to 60 per cent for adults. This difference is due to the greater frequency of cerebellar gliomas in children and to the infrequent occurrence of three common tumors usually found in adults; namely, meningiomas, acoustic neurinomas, and pituitary adenomas. The other important feature is that childhood neoplasms occur in the infratentorial region in about 65 to 75 per cent of the cases, whereas meningeal tumors of adults occur in the supratentorial region. Astrocytomas and medulloblasto...

Purpose: In radiotherapy (RT) of brain tumors, the primary motor cortex is not regularly considered in target volume delineation, although decline in motor function is possible due to radiation. Non-invasive identification of motor-eloquent brain areas is currently mostly restricted to functional magnetic resonance imaging (fMRI), which has shown to lack precision for this purpose. Navigated transcranial magnetic stimulation (nTMS) is a novel tool to identify motor-eloquent brain areas. This study aims to integrate nTMS motor maps in RT planning and evaluates the influence on dosage modulations in patients harboring brain metastases. Materials and Methods: Preoperative nTMS motor maps of 30 patients diagnosed with motor-eloquent brain metastases were fused with conventional planning imaging and transferred to the RT planning software. RT plans of eleven patients were optimized by contouring nTMS motor maps as organs at risk (OARs). Dose modulation analyses were performed using dose-volume histogram (DVH) parameters. Results: By constraining the dose applied to the nTMS motor maps outside the planning target volume (PTV) to 15 Gy, the mean dose (Dmean) to the nTMS motor maps was significantly reduced by 18.1% from 23.0 Gy (16.9-30.4 Gy) to 18.9 Gy (13.5-28.8 Gy, p < 0.05). The Dmean of the PTV increased by 0.6 ± 0.3 Gy (1.7%). Conclusion: Implementing nTMS motor maps in standard RT planning is feasible in patients suffering from intracranial metastases. A significant reduction of the dose applied to the nTMS motor maps can be achieved without impairing treatment doses to the PTV. Thus, nTMS might provide a valuable tool for safer application of RT in patients harboring motor-eloquent brain metastases.

Cerebellar abnormalities are encountered in a high number of neurological diseases that present in the neonatal period. These disorders can be categorized broadly as inherited (e.g. malformations, inborn errors of metabolism) or acquired (e.g. hemorrhages, infections, stroke). In some disorders such as Dandy-Walker malformation or Joubert syndrome, the main abnormalities are located within the cerebellum and brainstem. In other disorders such as Krabbe disease or sulfite oxidase deficiency, the main abnormalities are found within the supratentorial brain, but the cerebellar involvement may be helpful for diagnostic purposes. In In this article, we review neurological disorders with onset in the neonatal period and cerebellar involvement with a focus on how characterization of cerebellar involvement can facilitate accurate diagnosis and improved accuracy of neuro-functional prognosis.