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Background Cardioembolic stroke (CE) is usually associated with a larger ischemic area leading to higher morbidity and mortality rates. No biomarkers for CE are available, which causes difficulty in differential diagnosis of CE from other subtypes of acute ischemic stroke., Methods: We prospectively evaluated consecutive patients with acute ischemic stroke to identify biomarkers that could distinguish between CE and other subtypes of acute ischemic stroke. Etiological diagnoses were identified according to the National Institute of Neurological Disorders and Stroke (NINDS) 111 classification using clinical examinations, computed tomography (CT), magnetic resonance imaging (MRI), cardiac evaluations, and other tests. The biomarkers N-terminal pro-brain natriuretic peptide (NT-pro-BNP), Thrombin-Antithrombin III Complex (TAT), and D-dimer were determined in blood samples collected within 48 hours of onset and compared between groups with and without CE. Non- CE consisted of atherothrombotic brain infarction (ATBI), lacunar infarction (LI), and other stroke subtypes of unknown cause (other)., Results: This study included 279 patients diagnosed with acute ischemic stroke. Serum levels of NT-pro- BNP were significantly higher in those with than in those without CE stroke (p<0.0001). Analysis of receiver operating characteristics (ROC) curves indicated that an NT-pro-BNP cutoff of 332 pg/mL provided optimal sensitivity (98.3%) and specificity (75.8%) for distinguishing CE from non-CE., Conclusions: Serum levels of NT-pro-BNP may help in diagnosis of CE during the acute phase and thus allow appropriate therapy t6 prevent subsequent cardiogenic stroke.

A 55-year-old man presented with intracerebral hemorrhage (ICH) without subarachnoid hemorrhage (SAH) manifesting as acute onset of consciousness disturbance and right hemiparesis. Computed tomography showed ICH mainly localized in the left putamen, but no evidence of SAH. Magnetic resonance angiography demonstrated a cerebral aneurysm originating from the bifurcation of the left internal carotid artery, which was considered to be responsible for the ICH. The patient underwent emergent intravascular surgery for coil embolization of the aneurysm, and his neurological symptoms gradually recovered with rehabilitation after surgery. Although ICH without SAH is a rare presentation of cerebral aneurysm, ruptured cerebral aneurysm should be considered as a potential cause of ICH. The localization and extent of ICH may be suggestive of latent cerebral aneurysm in such cases.

A 21-year-old man presented with a hemorrhagic central neurocytoma manifesting as acute onset of disturbance of consciousness and right hemiparesis. Computed tomography (CT) demonstrated a tumor in the left lateral ventricle during the course of evaluation for mental alteration 12 days before onset, but the tumor was left untreated because the patient refused to visit a neurosurgical institution. CT on admission revealed a large mass lesion located in the body of the lateral ventricle associated with massive intratumoral and intraventricular hemorrhage. He underwent emergent surgery for evacuation of the tumor with hematoma, and his neurological symptoms gradually recovered after surgery. The present case highlights the possibility of rapid deterioration of symptoms by massive hemorrhage from central neurocytoma. Surgical intervention should thoroughly be considered, if intratumoral hemorrhage is present, as hemorrhage from the central neurocytoma may lead to serious neurological complications.

We discussed management strategies for unruptured aneurysms by an analysis of 62 treated and 48 untreated cases. The treated cases were divided into the following two groups; Group A consisted of 38 patients with 46 aneurysms treated during our initial 13 years (7 males, 31 females, 54 +/- 9 years old), and Group B of 24 patients with 32 aneurysms (8 males, females 16, 57 +/- 9 years old) during the last 3 years. In Group A, 36 patients were treated with neck clipping, except for two patients, who had giant aneurysms treated with internal carotid ligation and bypass surgery. All the patients in Group B were treated with either clipping or endovascular coil embolization. Our indications for coil embolization include patients with aneurysms located in paraclinoid internal carotid or basilar arteries, or with multiple aneurysms requiring more than one operation, or with a systemic risky disease for general anesthesia. In group A, 2.6% of cases resulted in death during operation and 10.3% of cases resulted in morbidity, while in group B, there was neither mortality nor morbidity caused by clipping, except for a patient with mild hemiparesis who had been treated with clipping for SAH caused by a procedure of coil embolization. The 50 aneurysms of 48 untreated patients have been observed without any neurosurgical treatment during periods of 6 months to 10 years with a mean of 2 years 7 months. Eventually, four aneurysms resulted in SAH, which cases were treated with emergency clipping or coil embolization. The high rupture rate (3.1% per year) in the natural history may suggest that some aneurysms are more likely to rupture than generally considered. We also reviewed operative findings of all entry clipping cases; more than 80 percent of aneurysms, including those measuring less than 5 mm in diameter, had red colored, thin wall domes with or without bleb. Our conclusion is that surgical indications are for a complementary use of clipping and coil embolization.

Operative indication and risk factors for unruptured cerebral aneurysms were discussed. During the past 11 years, 38 aneurysms in 33 patients with a mean age of 54 years were operated on. All aneurysms were located in the anterior circulation; 16 were of carotid artery, 15 of the middle cerebral artery, 4 of the anterior communicating artery, and 3 of the distal anterior cerebral artery. Six cases (18.2%) developed neurological deficits postoperatively. The deficits were permanent in 3 cases (morbidity 9.1%). There was one operative death (mortality 3.0%). Operative risk factors were analyzed in 4 particular cases. Of these 4 cases, two cases had large aneurysms (14 and 16mm in diameter) located at carotid-ophthalmic and at the inferior wall of the carotid arteries, respectively. One developed unilateral blindness possibly due to operative manipulation, and the other showed hemiparesis with aphasia due to postoperative carotid stenosis caused by clipping. Of the rest 2 cases; one with multiple (carotid and middle cerebral) aneurysms developed hemiparesis because of postoperative stenosis of the atheromatous parent artery caused by clipping, and the other, with a large (17mm) aneurysm at the distal anterior cerebral artery, died of postoperative intracerebral hematoma. Both of these cases were associated with cerebral ischemic disease. All cases that developed postoperative neurological deficits had varying degrees of hypertension. Reviewing our series and other reports, it can be said that age is one of the most important factors that influence operative mortality. However, a lower risk of rupture develops as age increases. For those under 70 years of age, operation is considered safe in healthy individuals, especially among those without hypertension. However, in cases where there are large aneurysms, multiple lesions, less accessible locations and cerebral ischemic disease, operative risks should be kept in mind. Operative morbidity in these cases is relatively high compared to that found among others. Therefore, planning a meticulous surgical strategy and further careful operative manipulation are essentials, when surgical treatment is indicated.

The authors present three patients with trigeminal neuralgia due to compression by an artery that transfixed the sensory root of the fifth cranial nerve. These cases represented 0.8% of 384 patients with trigeminal neuralgia treated by microvascular decompression at the authors' clinic during the past 12 years. In the remaining 381 cases, the compressing vessels were successfully removed from the trigeminal nerve without much difficulty, for an initial cure rate of 94.3%. In the three cases reported, however, the compressing artery penetrating the nerve could not easily be maneuvered away from the nerve. In the first two cases, partial rhizotomy perpendicular to the axis of the nerve at the site of arterial transfixion made it possible to separate the artery from the nerve. However, these two patients developed postoperative facial sensory impairment. In the third case, rhizotomy was performed longitudinal to the axis of the nerve at the site of arterial transfixion, making it possible to reposition the artery peripherally beyond the root entry zone of the nerve without causing any postoperative sensory deficits of the face. No recurrent pain has developed in more than 2 1/2 years since surgery in any of these three cases. When performing microvascular decompression surgery on patients in whom the compressing artery penetrates the nerve, the technique used in our third patient is the procedure of choice.

Two cases of spontaneous pneumocephalus, which developed after ventriculoperitoneal shunt procedures for severe hydrocephalus caused by benign brain tumors, are reported. In both cases there was no previous history of cerebrospinal fluid leakage. Operation revealed that both patients had many small defects of the dura mater and the bone in the middle cranial fossa, which were plugged by necrotic brain tissue. These defects were remote from the sites of the original tumors but may have been produced by long-standing raised intracranial pressure, and they presumably allowed air to enter after intracranial pressure was reduced by shunting. Repair of the defects prevented further intracranial air retention.

A case of benign chondroblastoma extending from the nasal cavity to the frontal region, was reported. A 1-year and 9-month old girl was admitted to our hospital in April 1981 because of generalized convulsion. On admission, she was intact neurologically and had It. nasal obstruction and It. eye discharge. Her laboratory examinations, including serum electrolytes and A1-P, were all in normal range. Plain skull X-P showed marked calcification from midfrontal region to the nasal cavity, and destruction of the frontal base especially in It. side. Plain CT showed isodensity mass with spotty calcification in the nasal cavity and marked high density mass in the frontal region. By contrast enhancement, nasal mass was markedly enhanced and new enhanced mass appeared around the intracranial calcification. Lt. ext. CAG showed the enlarged middle meningeal artery which is the feeder of the tumor, fine tumor vessels and slight tumor stain. Lt. int. CAG only showed the mass effect. After three-stage operation of bifrontal craniotomy, sublabial transnasal approach and rhinotomy, all the tumor was removed and she was discharged with no neurological deficits. The tumor was well demarcated and consisted from solid, cystic and calcified region. The solid region was grayish and easy-hemorrhagic. Histological examination revealed characteristic features of benign chondroblastoma, such as diffuse proliferation of polygonal or round cells, foci of chondroid matrices, scattered polynuclear giant cells and some mitosis.

The authors present the case of a 32-year-old female with a hard, bony mass on her left forehead, present for several years, which rapidly increased in size after she became pregnant. Neuroradiologically, the tumor appeared to have originated in the interosseous space, and it invaded the subgaleal and intracranial spaces as the pregnancy advanced. The tumor was explored and removed after delivery. Light and electron microscopic studies verified that it had the characteristics of a typical meningotheliomatous meningioma. Interosseous meningiomas are biologically and morphologically similar to intracranial meningiomas and must be followed carefully during pregnancy because of their potential for rapid growth at this time.

A rare case of a 14-year-old boy with a spontaneous (true) aneurysm of the superficial temporal artery is presented. The mass in the right parietal region was pulsatile and gradually enlarged in size for the last several months without any notable history of head trauma. The mass was successfully removed by surgery and has proved histopathologically to be a true aneurysm. While almost all cases of the superficial temporal artery aneurysm reported are traumatic ones, the true aneurysm of this artery which is verified by angiography is extremely rare. The pathology, etiology and treatment of this true aneurysm of the superficial temporal artery were discussed.

A 16-year-old boy who had undergone a ventriculoperitoneal (VP) shunt because of hydrocephalus at 8 years of age complained of pain around the right neck and chest. He concomitantly had a slight fever of unknown etiology, which had been lasting for several years. Skull and chest roentgenograms revealed an unusual calcified shadow around the shunt tube. After removal of the shunt apparatus, his pain and fever disappeared. Silicone tubes used in a VP shunt apparatus may induce fibrous connective tissue proliferation around the tubes in both children and adults, but no reports of radiologically verified calcification of a VP shunt tube are found in the literature, to the best of our knowledge. The possible mechanism of calcification of the VP shunt tube is discussed.