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脳梗塞による右大脳半球病変で右利き交叉性純粋語唖をきたした症例を報告した。症例は61歳の右利き男性で, 母親と弟は左利きである。 1990年11月21日, 急性心筋梗塞の診断で入院中に突然発話不能となった。神経学的には意識清明で, 左不全片麻痺, 著明な発声構音障害, 口部顔面失行を認めた。聴理解・読字・書字は正常であった。失語症, 仮性球麻痺や半側空間無視はなかった。頭部 CT および MRI では右中・下前頭回の限局性の脳梗塞巣が認められた。入院後, 著しい発語の緩徐化, 構音の歪み, dysprosody のために筆談を行なっていたが, 慢性期には構音障害や dysprosody の改善を認めた。本症例は左利きの家族性素因があり, 言語中枢が右半球優位で, 特に右中・下前頭回後部の発声構音に関する中枢が限局して障害されたと推察される。また, 発声構音過程には言語中枢優位側の中・下前頭回が重要な役割を担っていると考えられた。

The long-term clinical results of STA-MCA anastomosis as well as the medical treatments were compared in cases that were confined as having a focal cerebral perfusion deficit with viable brain tissue, based on either the drug induced EEG and evoked potential test (DEE test) and/or by positron emission tomography (PET). The criteria for viable cerebral tissue was determined by the following four conditions: (1) functional reversibility could be confirmed by the DEE test; (2) a haemodynamic process could be found in the DEE test; (3) a haemodynamic compromise could be confirmed in the PET study; (4) misery perfusion could be confirmed in the PET study. From 1975 to 1989, 55 cases were confirmed as having viable brain tissue according to the DEE test and the PET study. Of the 55 cases, bypass surgery was performed on 35. Conservative treatment was given to the other 20 cases. There were 3 cases of perioperative neurological deterioration. One was permanent and the other 2 were transient. Results of the long-term follow up are as follows, Ipsilateral attack: 1 case (2.0%) received surgery, and 7 cases (35%) received conservative treatment. Re-attack in the contralateral or posterior circulation: 6 cases (17.2%) received surgery, and 1 case (5%) received conservative treatment. Seventy-seven per cent of the surgical cases improved or had no change in the final functional status, while only 55% of the conservative group either improved or showed no change. The incidence of ipsilateral cerebral ischaemia was significantly low in the surgical group. Contralateral and/or posterior circulation ischaemia tended to be high in this group, however.(ABSTRACT TRUNCATED AT 250 WORDS)

A series of 105 patients presenting with multiple aneurysms and subarachnoid hemorrhage (SAH) were operated on for ruptured and unruptured aneurysms between 1976 and 1984. Clinical factors other than the severity of SAH affecting the outcomes included: 1) Misdiagnosis of the location of a ruptured aneurysm among multiple aneurysms resulted in poor outcomes because of multiple surgical approaches or rebleeding during the acute period. 2) Combinations of aneurysmal locations requiring multiple surgical approaches, such as interhemispheric and transsylvian, during the acute stage caused worse outcomes than with multi-stage surgeries. If an unruptured aneurysm could not be reached during the initial exposure, multi-stage surgery was safe if the ruptured aneurysm had been clipped during the acute period. 3) Complications occurring during unruptured aneurysm surgery. The patient's age, the location and size of the unruptured aneurysms were significant factors in the clinical prognosis. Surgery for unruptured aneurysm caused 1.8% morbidity in patients between 28 and 55 years, but 18.0% morbidity in patients over 56 years of age. Surgery for internal carotid artery aneurysms resulted in 14.8% overall morbidity. Surgery for middle cerebral and anterior cerebral artery aneurysms caused below 5% morbidity. Postoperative morbidity in patients with aneurysms less than 5 mm in diameter was 1.3%, and with aneurysms measuring 10 mm or more, 20%. The optimum treatment for multiple aneurysms with SAH should be based on all factors of the patient's condition, including the unruptured aneurysms.

In order to study the haemodynamic and metabolic changes following bypass surgery, the regional cerebral blood flow (rCBF), the oxygen extraction fraction (rOEF), the cerebral metabolic rate of oxygen (rCMRO2), and the cerebral blood volume (rCBV) were measured using a positron emission tomograph (PET) on 13 patients who had unilateral internal carotid artery and/or middle cerebral artery occlusion. The patients were divided into two subgroups according to pre-operative rOEF values from the arterial occlusion side: the misery perfusion group, which had high rOEF values (> or = 0.56), and the coupling perfusion group, which had normal rOEF values (0.38-0.48). A post-operative PET study was performed 1-2 months and/or 1-5 years following the surgery. Six of the misery perfusion cases showed a post-operative CBF increase, where an accompanying OEF decreased to its normal level, indicating an attenuated misery perfusion state. The CMRO2 values, however, remained low. The other 7 coupling perfusion cases had an ipsilateral CBF increase in the earlier PET study. We conclude that misery perfusion is attenuated following bypass surgery, although the procedure does not consistently improve oxygen metabolism.

The outcome of cerebral vasospasm in aged patients with ruptured intracranial aneurysms was compared with that in younger patients. Patients with brain damage due to previous stroke, intracerebral hematoma, or surgical complications were excluded from the study. The study population consisted of 143 patients hospitalized between 1982 and 1986. Neck clipping of ruptured aneurysms and continuous ventricular drainage were carried out within 3 days after onset. At 3 months after subarachnoid hemorrhage the incidence of poor clinical results was significantly higher in patients over 64 years of age than in younger patients (p

CT導入後に経験した破裂末梢性前大脳動脈瘤29例をまとめ, その臨床的特徴を検討した.男性13例, 女性16例で年齢は36～77歳, 平均55歳であった.これは同期間に入院した全破裂脳動脈瘤の4.1%に相当した.20例に対し手術を施行.6例 (21%) はazygos ACAを合併していた.10例 (34%) は多発性動脈瘤で15個の未破裂動脈瘤を認め, その内の9個は前大脳動脈領域で, 血行力学的要因が動脈瘤の成長, 破裂へ関与する事を示唆した.脳内血腫の合併は15例, 52%と高頻度.保存治療9例中8例は大量の脳内および脳室内血腫の合併例で死亡.手術例20例では13例が完全自立, 2例は自立, 1例は要介助, 2例が全介助, 2例が死亡した.手術例20例中18例は血腫を合併しないか小血腫例であった.末梢性前大脳動脈瘤は発作後短時間に大血腫や高度の脳室内血腫を合併, 高度の意識障害を来たし予後不良な激症型と, 意識障害, 合併血腫ともに軽度で予後良好な軽症型とに大別可能であった.

The author herein reports a new operative approach, the basal interhemispheric (BIH) approach, for anterior communicating artery aneurysms (ACo AN). This approach is a modification of the anterior interhemispheric (AIH) approach developed for lesions in and around the anterior third ventricle. The patient is fixed in the supine position and the head is dorsiflexed. A bicoronal skin incision is made behind the hairline and subperiosteal dissection of the skin flap is performed to the nasion and both upper portions of the orbits. The supraorbital nerves must be preserved in this procedure when the nerves penetrate the supraorbital foramina. A bifrontal craniotomy is performed as in the routine AIH approach and then an additional craniotomy is performed in the basal frontal and nasal bones. A small dural incision is made in the mid-basal portion of the right side. Microsurgical dissection of the interhemispheric fissure is performed directly toward the pre and suprachiasmatic areas near the folded portion of the arachnoid membrane, instead of the knee portion of the corpus callosum as in the AIH approach. Thus, the approach to the aneurysm can be performed using a shorter and more limited interhemispheric dissection than with the AIH approach. After the intradural procedure, the dura should be closed water tight, the additional bone flap is fixed, and then the area of the opened frontal sinus is completely covered with periosteum. The bifrontal bone flap is secured at four points and skin and galea are closed in the usual manner. The bifrontal bone flap is removed for external decompression if necessary. Fourteen cases of ACo AN (clear consciousness: 7 cases, drowsy state: 6 cases, semicoma: 1 case) have been operated on up to the present time, and all cases have recovered to a good condition. Furthermore, they don't show any cosmetic problem due to additional midline bone flap. It should be stressed that ACo AN can be approached with minimum brain retraction and dissection of the interhemispheric fissure using this BIH approach. This is a most important point in surgery for ACo AN in the acute stage.

The clinical significance of intracerebral hematoma (ICH) following rupture of a middle cerebral artery (MCA) aneurysm was studied in 31 surgical patients having a mean age of 52 years. Sixteen patients were not included in this study, because of massive intraventricular bleeding (2), postoperative complications (7), operation trouble (5), and symptomatic vasospasm (2). One patient died in postoperative period. The remaining 30 patients were followed for a mean of 3.7 years postoperatively. Sixteen patients almost fully recovered, nine were self-sufficient with some deficits, two were partially dependent, one was fully dependent, and three died. The locations of the ICH were as follows: temporal lobe in 18 cases; frontal lobe in five; frontal and temporal lobes in three; temporal and parietal lobes in four; and temporal lobe and internal capsule in one. Fourteen patients had permanent neurological deficits. Left homonymous hemianopsia occurred in one patient who had a large hematoma in the right temporal lobe but became self-sufficient. Motor disturbances were mild in 11 cases, and severe in three (hemiplegia in two and tetraparesis in one). Six of the 11 patients with dominant hemispheric ICH experienced motor dominant aphasia and one had global aphasia. Although there was no definite correlation between hemisphere and outcome, patients with medium to large ICH in the dominant hemisphere tended to develop motor dominant aphasia. In terms of motor disturbance and aphasia due to ICH following MCA aneurysm rupture, the prognosis appears fairly good because these ICH are originally subcortical.

The effect of serotonin (5-HT) and its antagonist ketanserin on the cerebral circulation was investigated in two series totaling 24 cats using the cranial window technique. 5-HT elicited a marked dilatation of small pial arteries, whereas large arteries tended to constrict. Intravenous administration of ketanserin reversed the constriction of large arteries, causing dilatation, and reduced the extent of small arteries' dilatation. In a randomized study, i.v. administration of ketanserin in its solvent versus the solvent alone revealed a strong dilatatory effect of the solvent on pial arteries (17 ± 1.8%), which partly jeopardized a possible constrictory effect of ketanserin, as ketanserin plus solvent induced less dilatation of small pial arteries than the solvent alone. The present data support the view that serotonin exerts a dual effect on cerebral arteries, namely, dilatation of small and constriction of large vessels. The antagonist ketanserin reverses this effect, but the strong dilatatory effect of the solvent alone masks the antiserotoninergic effect.

The lumen diameters of the main cortical surface arteries were continuously monitored through a closed cranial window in spontaneously hypertensive rats (SHR) and normotensive Wistar Kyoto rats (WKY). The arterial diameter was significantly smaller in SHR (55 +/- 1 micron) than in WKY (87 +/- 1 micron) during resting conditions as well as during hypercapnic dilatation (87 +/- 2 micron compared to 117 +/- 5 micron). The per cent increase in diameter induced by hypercapnia was larger in SHR (54%) than in WKY (36%), presumably a consequence of the altered vascular wall to lumen ratio. Alpha-adrenoreceptor blockade with yohimbine and phenoxybenzamine had no significant effect on arterial diameter during hypercapnia. The diameters of the largest pial surface veins increased to the same extent in SHR and WKY during hypercapnia (about 10%).

The oxygen extraction fraction (OEF) at maximally vasodilated tissue in patients with chronic cerebrovascular disease was evaluated using positron emission tomography. The vascular responsiveness to changes in PaCO2 was measured by the H215O autoradiographic method. It was correlated with the resting-state OEF, as estimated using the 15O steady-state method. The subjects comprised 15 patients with unilateral or bilateral occlusion and stenosis of the internal carotid artery or middle cerebral artery or moyamoya disease. In hypercapnia, the scattergram between the OEF and the vascular responsiveness to changes in PaCO2 revealed a significant negative correlation in 11 of 19 studies on these patients, and the OEF at the zero cross point of the regression line with a vascular responsiveness of 0 was 0.53 ± 0.08 (n = 11). This OEF in the resting state corresponds to exhaustion of the capacity for vasodilation. The vasodilatory capacity is discussed in relation to the lower limit of autoregulation.

A patient with the chondroid variant of chordomas at the skull base is presented. This 49-year-old female complained of diplopia. Examination revealed right abducens palsy only. The cause of the abducens palsy could not be demonstrated. 4.5 years later, she showed right abducens paralysis and mild dysesthesia in the distribution of the second division of the right trigeminal nerve. Pathological findings revealed physaliphorous cells, which indicated typical chordoma. A large amount of mucin was seen in the stroma. Typical cartilaginous cells were not proved. These findings indicated the transitional form between typical chordoma and chondroid chordoma. Dysesthesia of the right side of her face disappeared postoperatively. She has had a good clinical course for the ensuing year. It has been reported about chondroid chordoma that the more chondroid the tumor the longer the survival. To distinguish chondroid variants among chordomas is very important for prediction of the survival time. In cases with a chronic abducens paralysis, careful investigations should be performed to rule out a parasellar tumor. Reinvestigation is necessary immediately after the appearance of other neurological abnormalities.

The purpose of this study was to elucidate the clinical significance of intracerebral hematomas (ICH) following aneurysmal rupture. The subjects were 115 patients (mean age, 59 years) with ruptured aneurysms associated with ICH. The sites of the ruptured aneurysms were the middle cerebral artery in 53, the anterior communicating artery in 35, the distal anterior cerebral artery in 15, and the internal carotid artery in 12. The aneurysms were surgically treated in 94 cases. Pre-operatively, 13 were completely conscious, 26 were drowsy, 25 were stuporous, 21 were semicomatose, and nine were comatose. The interval between the last attack of bleeding and surgery was 24 hours or less in 63, 2 to 3 days in 18, 4 to 14 days in 11, 20 days in one, and 29 days in one. The mean follow-up period was 3 years. Forty-two patients died. Among the remaining 73 patients, 40 recovered with minimal or no neurological deficit, 16 had significant deficit but were able to function independently, three required partial assistance, and 14 were fully dependent. To more clearly assess the clinical significance of ICH, the authors separately evaluated the outcomes of the 79 patients who did not have intraoperative or postoperative complications, massive intraventricular hematomas, or symptomatic vasospasm, all of which influenced the clinical course markedly. Of these 79 patients, all 17 who did not undergo surgery died, while five surgical patients did not survive. Of the remaining surgical patients, 40 had complete or near-complete recovery, 13 were independently functional but had significant neurological deficit, two required assistance, and two were entirely dependent. There was no difference in outcome between patients with dominant-side and those with nondominant-side ICH. The favorable surgical results may be attributable to the fact that most operations were performed as soon as possible following aneurysmal rupture and the ICH were mainly subcortical. Also, among surgical cases, the incidence of symptomatic vasospasm was half that observed by the authors previously in patients without ICH. In all patients with bilateral, medium-to-large hematomas the outcome was poor regardless of whether or not surgery was performed.

Between 1973 and 1985, superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis was performed in 125 patients with steno-occlusion of the internal carotid or middle cerebral artery. Patients with moyamoya disease were excluded. One hundred twenty patients were followed for an average of 5.1 years (range, 0 to 12.5 years). The patients were divided into four groups according to the degree of neurological deficit. Mild neurological deficit (MiND) was observed in nine patients with transient ischemic attacks, six with reversible ischemic neurological deficits, nine with minor stroke who underwent surgery within 3 weeks of onset, and 37 with minor completed stroke. The moderate neurological deficit (MoND) group consisted of five patients with major stroke who were operated within 3 weeks and 12 with major completed stroke who had incomplete hemiparesis. Among the patients with severe neurological deficit (SND) were seven with major stroke and 19 with major completed stroke and, complete hemiparalysis. The fourth group included 16 patients with acute progressing stroke (APS). The results of follow-up in the MiND group were consistent with those of the International Cooperative Study of Extracranial/Intracranial (EC/IC) Arterial Anastomosis. Drug-induced electroencephalography and evoked potential test was performed in 60 cases. Hemodynamic competence was confirmed by means of induced hypotension in seven MiND patients, none of whom had further cerebral ischemic attacks. Reversibility of neurological deficits (ischemic penumbra) was demonstrated during induced hypertension in eight cases (two of MiND, three of MoND, and three of APS). In all of these cases the neurological status improved. Cerebral blood flow (CBF) was measured under induced hypotension in 13 cases, and two patients in the MiND group showed reduced CBF and had no further cerebral ischemic attacks. These results suggest that it is essential to document hemodynamic competence and reversibility of functional deficits (ischemic penumbra) in patients being considered for EC/IC bypass.

A pineocytoma in an old man, whose initial symptoms resembled a normal pressure hydrocephalus, is reported. This 67-year-old man gradually became uncommunicative and difficult to walk alone in three months. Just before visiting our clinic, his family also noticed his nocturnal urinary incontinence. CT scan on admission disclosed tumor in the posterior wall of the third ventricle, and subsequent hydrocephalus. This oval, isodense tumor was homogeneously enhanced after the injection of contrast medium on CT scan.

Clinical gradings for the cerebral aneurysm, advocated by Botterell, Nishioka or Hunt have been commonly used for evaluating the patient condition and the indication of the aneurysm surgery. In this study, new clinical grading classifying the patient condition according to their level of consciousness, herniation sign and also the accompanying conditions, which are evaluated by computerized tomography (CT) and angiography were reported. These include massive subarachnoid hemorrhage (SAH) in CT, intracerebral hematoma (ICH) with mass signs, such as midline shift and deformity of the ventricle, and vasospasm (VS) detected in angiography. Clinical results of the treatment for aneurysm cases in the acute stage are also reported. Two hundred ninety-one cases of anterior communicating, internal carotid and middle cerebral artery aneurysms which were admitted within 7 days after the last attack were studied. Of these 260 cases were operated on. The mortality of all cases was 16.2% and the morbidity was 13.7%. Number of cases having accompanying conditions were increasing as the grading. Most of the cases in grade 2 and 3 without accompanying conditions recovered to a good condition, except for cases with a rebleeding attack after the admission. The cause of the poor outcome in grade 2 and 3 with SAH and VS was cerebral ischemia following VS. Incidences with the two or three accompanying conditions increased in cases with grade 4 or more. Twenty out of 28 severe cases in grade 5b and 6 showed massive ICH on admission. Good outcome in cases with grade 4 or more were obtained in cases without VS. The accompanying conditions showed the cause of severity in a high grade case and helped to estimate the secondary pathophysiological state and to take preventive methods against it in a low grade case. Acute hydrocephalus was not rated as an accompanying condition, because no correlation was found between clinical severity and outcome. Clinical grading, based on level of consciousness, herniation signs and accompanying conditions were well correlated with the outcome and showed the operative timing and indication.

Cerebellar infarction is a rare disease, when compared with the incidence of supratentorial ischemic infarction among patients with arteriosclerosis. Thus, in a study of Hinshaw et al5 49 out of 6964 patients consecutively examined by CT-scan had cerebellar infarction. Before the CT-scan era, unspecific neurological symptoms made the clinical diagnosis in the acute stage virtually impossible.

After perfusion-fixation pial arteries and veins showed a statistically significant dilatation calling in question the usual definition of veins with regard to their diameters. Immunohistochemical investigations revealed that arteries and veins, but not capillaries, contained smooth muscle myosin. The need for a correlation between immunohistochemical and electron microscopic results by the application of immunocytochemical methods on the ultrastructural level is stressed.

The mechanism of the production of the intracerebral hematoma in cerebrovascular moyamoya disease is still being debated. The authors experienced a case, whose intracerebral hematoma was evacuated 18 hours after the ictus. During the operation, a hematoma ball near the bleeding point in the hematoma cavity was extirpated and used for preparing pathologic specimens. Four hundred serial specimens, 4 μm in thickness, showed abnormal perforating arteries, the diameter of which was around 300 μm. The wall of these vessels presented variable intimal elastofibrosis and tortuosity of internal elastic laminae, resulting in irregular narrowing or dilatation of vessels. In addition, many disrupted arterioles, the size of which ranged from 50 to 150μm in diameter, were found. The walls of these smaller vessels were not accompanied by the fibrinoid necrosis change and presented almost the same changes as were seen in the larger ones, but to a smaller extent. These arteriolar changes were considered to evolve during the formation of the hematoma. So long as there is production of intracerebral hematoma, these findings indicate that the pathologic mechanisms in moyamoya disease are similar to those in hypertensives, especially in the massive type.

1. The diameters of main cortical surface branches of the middle cerebral artery were continuously monitored through a closed cranial window in spontaneously hypertensive rats (SHR) and in normotensive Wistar Kyoto (WKY) rats by aid of a multichannel video-angiometer under resting conditions and under maximal vasodilatation induced by hypercapnia. 2. Initial mean arterial pressure was 172 ± sem 9 mmHg in SHR and 103 ± 5 mmHg in WKY rats; during hypercapnia the corresponding values were 183 ± 9 and 127 ± 7 mmHg. 3. The resting diameter of the arteries was 55 ± 1 μm in SHR (n = 53) and 87 ± 1 μm in WKY rats (n = 53; P < 0.001). The percentage increase in diameter during vasodilatation (Paco2 70 mmHg) was larger in SHR (54%) than in WKY rats (36%). However, the maximum lumen diameter remained significantly smaller in SHR (84 ± 2 μm compared with 117 ± 5 μm in WKY rats; P < 0.001). No significant further dilatation was seen in either group after α-adrenoceptor blockade. 4. The smaller diameter of cortical arteries during vasodilatation is consistent with the concept that hypertensive vascular hypertrophy encroaches on the lumen in vivo. The larger percentage increase in diameter of cortical arteries in hypertensive rats corroborates Folkow's hypothesis on the haemodynamic consequences of an altered media/lumen ratio in hypertension. 5. There is no evidence that an enhanced sympatho-adrenergic tone prevents maximum vasodilatation during hypercapnia in SHR.