We have already emphasized the intimate correlation between migrainous attacks and intracranial vascular abnormality. The purpose of this paper is to report clinical character-istics of migrainous patients who showed angiographically intracranial vascular abnormali-ties as second report successively.
Case 1: A 64-years-old female had the only occipital throbbing headache with the visual or auditory auras from five years ago.
Bilateral carotid and vertebral angiography showed an obviously poor filling of the right posterior cerebral artery at every trials.
Case 2: A 28-years-old male had had repeated attacks of migraine after few minutes of scintillating scotoma. On admission he had no neurological deficit. The contrast en-hanced CT scan revealed a paraventricular high density area at the left trigon. Left carotid angiography demonstrated the small angioma at the region above stated, which was fed from the left posterior cerebral artery via the left posterior communicating artery.
Case 3 : A 29-years-old female had had mainly right migraine attacks since age of nineteen-years-old. Since 24-years-old of first delivery, the patient has developed migraine with scintillating scotoma as an aura. There were no neurological abnormality, but E. E. G. showed slow wave burst in the bilateral fronto-parietal region by hyperventilation. A large arterio-venous malformation was recognized in the right occipital region, fed by the anterior-, middle- and mainly posterior cerebral artery on the right side.
After the total removal of this AVM, migraine attacks disappeared.
Case 4: A 48-years-old female complained vertigo and fainting spells since age of 32-years-old. The patient had had migrainous attacks associated with the aura of left homo-nymous visual narrowing. On admission she had no neurologioal deficits. The E.E.G. examination showed 6-7 c/s theta wave burst in all lead, built up by hyperventilation.
Right carotid and vertebral angiography demonstrated the giant gobang-like arterio-venous aneurysms in the posterior infracallosal and Galen's region. This aneurysms were fed by two abnormal vessels from the right posterior cerebral artery.
The authors speculated that the abnormal filling of unilateral posterior cerebral artery and posterior communicating artery (vertebro-basilar system) might cause a circulatory instability of the diencephalon and upper brainstem. Therefore, such a instability of these region might be easy to induce the neuronal or humoral trigger of migrainous attack. Angiographic finding in these four cases lead us to consider that there may be an intimate correlation between migrainous attack and intracranial vascular abnormality in some patients.

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Probably due to the change in living circumstances and elevation of living standard, there have been an increased number of patients recently complaining of headache or heavy feeling in the head, and with these symptoms more patients seem to consult the clinics of internal medicine, neurology, neurosurgery, etc. than the clinic of ophthalmology. How-ever, among these there are unexpectedly many cases due to anomaly of refractive ad-justment, the most popular problem, especially in severe cases causing attacks of uncon-sciousness sometimes. It seems to be caused by sitmulation of oculogastro-cardial reflex pathway. We have observed statistically 116 cases having headache among 1, 160 cases for whom we prescribed glasses in one year from June 1, 1978 through May 31, 1979. Namely, ca. 76% of them had symptoms improved by the use of proper glasses, and it has become clear that adjusting power is decreased with the age. From these facts, it has become clear that anomaly of refractive adjustment is one of important factors for the cause of headache.

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We experienced 325 cases of patients who had headaches as a chief complaint at our out-patient clinic from January, 1977 to September, 1979. Occipital and trigeminal neuralgias consist 149 cases (46%) as a main cause of headache followed by vascular headache (19%), subarachnoid hemorrhage (18%), increased intracranial pressure (15%) and others (2%). Classification of headache in our clinic is much different from that of Ad Hoc Committee, because we need to represent basic mechanism of headache from surgical points of view. So-called muscle-contraction headache of nuchal or temporal muscles is included in occipital and trigeminal neuralgias, as far as tenderness is present on greater occipital, smaller occipital and/or trigeminal nerves, and nerve blocking by local anesthetics eliminates the pain temporarily.
Twenty-one out of 149 cases (14%) were operated to relieve the headaches related to occipital and, /or trigeminal neuralgias, in which the main cause of headache was trigeminal neuralgia in 8 cases and occipital neuralgia in 13 cases. In trigeminal neuralgias, one case of tic douloureux was treated by Frazier's gasserian ganglionectomy and seven cases of symptomatic trigeminal neuralgias (giant IC cavernous aneurysm 1, unruptured MCA aneu-rysm 1, pituitary tumor extended into sphenoid sinus 1, cerebello-pontine-angle tumor 2, metastatic craniobasal tumor 2) were respectively treated by trapping or clipping of aneu-rysms, total removal of tumors or trigeminal rhizotomy. Over-all effects of surgery were disappearance of the headache in 5 cases and improvement in 3 cases. Out of 13 cases of occipital neuralgias, 4 had cervical spinal lesions(cervical spondylosis 2, cervical disc herni-ation 2), one had dural AVM and the other 8 had posttraumatic or nontraumatic thoracic outlet syndromes (TOS). Anterior body fusion with full removal of osteophytes abolished the headache in all 4 cases of cervical spinal lesions. Total removal of the AVM got the headache disappeared. After division of the anterior scalene muscle with hypertrophic, fibrous or tendinous portions through supraclavicular approach, various symptoms and signs such as occipital and/or trigeminal pain, visual disturbances, stiffness of neck and shoulder muscles and restriction of neck movements were disappeared in 5, improved in one and unchanged in 2 cases. We would like to emphasize an importance of TOS as a cause of occipital neuralgia, because TOS is encountered more frequently than expected in post-traumatic soft tissue neck injuries and furthermore treated successfully by the division of the anterior scalene muscle.
As far as surgical treatment of troublesome headaches gives dramatic and long-lasting relief to many patients, neurosurgeons must examine patients carefully to find real causes of headache intracranially and extracranially for the best treatment.

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Eight procedures of selective radiofrequency thermocoagulation of trigeminal nerve root were performed on 7 patients with idiopathic trigeminal neuralgia and 2 procedures on 2 patients with symptomatic trigeminal neuralgia from malignant neoplastic diseases. This technique is a safe procedure with low morbidity and superior to the other treatments be-cause analgesia can be obtained in the desired areas with preservation of touch sensation.

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The symptoms just after the aneurysm rupturing were analized in 694 single cases treated by intracranial direct surgery.
The attacks due to rupture of aneurysm were devided into three types according to the lasting time of unconsciousness.
These were, the minor attack-episode of headache without unconsciousness, the moder-ate attack-episode of headache associated with unconsciousness lasting less than one hour and the major attack-episode of headache associated with unconsciousness lasting more than one hour. The minor attacks in initial bleeding were observed in 441 of 694 cases (64 percent), the moderate attacks in 95(14 percent)and the major attacks in 149 (22 percent). From the operative findings the subarachnoid hemorrhage in cases with a major attack was massive and widely spread out, while in minor attacked cases it was slight. This differ-ence was significant in anterior communicating artery (A com A) aneurysm cases.
The statistical significance of the site of severe headache according to the aneurysmal site were obtained in bilateral fronto-occipitonuchal pain in A corn A aneurysm (P<0.05) bilateral parieto-temporal in anterior cerebral artery (ACA) aneurysm (P<0.01), ipsilateral headache in internal carotid (ICA) and middle cerebral artery (MCA) aneurysm (P<0.01) and ipsilateral retro-ocular pain in ICA aneurysm (P<0.01).
The site of numbness and motor disturbance of the extremities were correlated with the site of the responsible aneurysms. Unilateral or bilateral lower extremities in A corn A and ACA aneurysms were characteristic.
Ocular motor disturbances were observed most frequently in ICA aneurysm cases and almost all of them (97.1 percent) were the unilateral third nerve palsy. Visual field defects were observed in seven anterior communicating artery, six internal carotid artery and one basilar artery aneurysm cases.
Retinal hemorrhage were seen most frequently (28 percent) soon after the aneurysm rupture, but choked disc developed one or two weeks after the aneurysm rupture (32 percent).

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Efficacy of nifedipine administration alone or combination therapy of isoproterenol and aminophylline on the angiospasm caused by ruptured aneurysms was assessed in 19 cases and 25 cases respectively.
The result was evaluated with comparison of the state of consciousness before and after the treatment. In the treated cases, the neurological improvement was observed to be better than that of untreated cases.
The mode of onset, especially the duration of unconsciousness and its subsequent course, is seemed to be playing an important role in the determination of the final outcome of subarachnoid hemorrhage. Prognosis in cases with angiospasm can be largely predicted by the above-cited initial profile of subarachnoid hemorrhage rather than pre-treatment level of consciousness. That is to say, if the mode of onset and its subsequent course are graded as a severe type, the results of treatment of both regimen will be poor. On the contra-ry, if it is graded as a mild type, the final outcome will be excellent. In the group of “moderate” type in grading, optimal and proper treatment can result in satisfactory course.
Combined isoproterenol and aminophylline therapy is capable to reverse the course of the case, the “moderate type”, in which the deterioration is begining. Nifedipine therapy is advisable for prophylactic use in the “mild” or “moderate” type of vasospasm.

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We have studied the correlation among the findings of computed tomography, the clini-cal severity at the time of onset and subsequent development of the cerebral infarction due to vasospasm were studied on the 32 cases with subarachnoid hemorrhage secondary to in-itial rupture of cerebral aneurysm. It was found that the clinical severity was able to judge by CT correlated with the amount of blood in subarachnoid space. Furthermore, it was possible to predict the subsequent occurrence of cerebral infarction by initial and subse-quent findings of CT. Hounsfield number of high density area in the subarachnoid hemor-rhage over 60 showed good correlate with the development of cerebral infarction.

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We report the characteristics of Computed Tomography (CT) findings about 45 suba-rachnoid hemorrhage (SAH) patients mainly due to ruptured aneurysms. They are from 21-to 70-years-old of age, 17 males and 28 females.
Within the third week after the onset, extravasated blood appeared. High density area was found in 15 of 16 ruptured aneurysm patients (94%) on CT-scan performed within 3 days after the onset of SAH.
High density areas are seen in patients of Hunt's grade III, IV, and V. Massive intra-ventricular hemorrhage (IVH) are found in patients of grade IV and V.
In anterior communicating aneurysm hemorrhage of suprasellar cistern expands sym-metrically to ambient cistern and anterior interhemispheric fissure.
In distal anterior cerebral aneurysm hemorrhage involves anterior interhemispheric fissure.
In internal carotid aneurysm hemorrhage involves suprasellar cistern & Sylvian fissure of ruptured side and then expands to other basal cisterns.
In middle cerebral aneurysm hemorrhage involves Sylvian fissure of ruptured side and makes intracerebral hematoma in temporal or frontal lobe at the rate of 75%.
Aneurysm itself by contract enhancement (CE) was found in 8 of 9 cases.
High density areas of lesion were seen in arterio-venous malformation and head trauma patients. IVH was seen in Moyamoya disease patients.
The wider SAH is, the higher mortality is, IVH due to ruptured aneurysm signifies poor prognosis.
We should perform CT-scan of SAH patients as soon as possible. We have to examine circle of Willis chiefly and do it by CE, if possible.

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There are few detailed reports on the cerebral arteriovenous malformation associated with hematoma, in spite of the fact that this clinical state necessitates emergency operation.
Twenty-two cases of arteriovenous malformation which have been experienced in our clinic were analyzed in this regard. CT scan has made it easy to find out intracerebral hematoma, but in the case of arteriovenous malformation the cerebral angiogram is indis-pensable for its exact diagnosis. Of 22 patients 19 had bleeding episodes and 10 came to our clinic associated with hematoma, 6 were supratentorial and 4 infratentorial. An extremely acute course was observed in 8 including all 4 infratentorial cases and all of them were operated within 48 hours from onset. Other 2 cases were acute and subacute, and the both were supratentorial. In 8 cases the evacuation of intracerebral hematoma and total extir-pation of the arteriovenous malformation were performed at the same time, but in the case of arteriovenous malformation of the brainstem, extirpation of the arteriovenous malfor-mation was impossible and only intracerebellar hematoma was evacuated.
The prognosis for operative treatment of hemorrhages from arteriovenous malformation was good for the supratentorial cases, but bad for the infratentorial ones, in which only one case of cerebellar arteriovenous malformation associated with hematoma was saved without any residua.

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A case of arterial sac of the great vein of Galen in a one year and 5-months-old male infant is presented, and he is the 50th case reported in the world so far. The patient developed generalized convulsion and increased circumference of the head since one year after his birth. On admission his head circumference was 52.5 cm and fontanelle was still open without bulging. No remarkable neurological findings but slight anisocoria were noted. A large round isodense mass continuous to a smaller one in the midline was demonstrated by CT scan in the trigonum of the left lateral ventricle. Ventricular dilatation and widening of subarachnoid space were also disclosed. The left carotid and right vertebral angio-graphy revealed an enormously large aneurysmal sac at the great vein of Galen which was fed directly by posterior cerebral arteries on both sided. Draining vein was dilated rectal sinus. Following several shunting procedures, right parieto-occipital craniotomy was per-formed. The feeding arteries were clipped at the entrance to the small arterial sac via the interhemispheric approach. The patient expired from laryngospasm 24 hours after the operation. No autopsy could be obtained.
This anomaly seen in the region of the great vein of Galen is generally entitled as aneurysm in spite of conspicuous difference between the usual saccular aneurysm treated around the circle of Willis. Therefore, we proposed a new term, arterial sac of the great vein of Galen, to avoid the confusion between them. The steal of the cerebral blood flow to the sac which results in the cortical atrophy and passive hydrocephalus is postulated as more important cause of hydrocephalus than the obstruction of the aqueduct by the sac. The direct attack to the sac, either total removal or only clipping of feeding arteries, is recommended with expectation of disappearance of the steal phenomenon.

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The quantitative, specific and direct method for analysis of urinary catecholamines has been reported by us in elsewhere. With this method we tried to follow up urinary cate-cholamine levels in patients with cerebral arterial aneurysm during surgical treatment. Since the amount of urine excreted in an unit of time varied to a large extent, we used values of urinary catecholamines corrected by the glomerular filtration rate as the parame-ter. It was found that catecholamine values (corrected)were much higher (over 1, 000pg/ml) in patients in a condition of elevated cerebral pressure than those in the usual condition. On the basis of the present finding, it is suggested that urinary catecholamine level was feasible as a parameter leading to the estimation of high cerebral pressure status encounter-ed during surgical treatment.

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There have been no favorable results achieved by the current direct surgical operations for treatment of giant cerebral artery aneurysm even in today's medical society with micro-surgical techniques.
The authors succeeded in the direct operation of the giant anterior communicating artery aneurysm of which extended even to 40×40×35mm in the upper region within the saddle. This patient, a 54-years-old male, was suddenly attacked with severe headache and un-consciousness in March 1968. Since then he complained headache and became aware of decreased visual acuity in his right eye. He visited an eye clinic and was referred to us under the suspicion of parasellar tumor.
Cerebral angiogram revealed a giant aneurysm of the anterior communicating artery. CT scan revealed a ring shape high density area and its high density area enhanced by conray infusion. Direct operation was done with success under administration of 20% mannitol.
Details of our operative method of giant aneurysm at the anterior communicating artery were discussed.

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With the spread of computed tomography, we often see easily the intracerebral hema-tomas in children, which causes have not been cleared up.
We experienced such 3 cases. They are as follows:
1) Intracerebral hematomas in both frontal lobes (2-years-old girl)……cause unknown after operation.
2) Pontine hematoma (4-years-old boy)……cause unknown after autopsy. 3) Intracerebral hematoma in parietal lobe (6-years-old boy)……which is caused by arterio-venous malformation.
From the above 3 cases, we concluded that the such hemorrhage are related to “cryptic” or some vascular malformations.

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Introduction of by-pass surgery has been a most important advance in the treatment of so-called “Moyamoya” disease in a last decade. According to statistical studies by Nishimoto and et al. (5, 6), such children with this disease manifest predominantly ischemic disorders such as TIA or infarction, both of which consist 68% of etiological mechanisms for the onset of the disease. Therefore, by-pass surgery seems to be indicated for children's Moyamoya disease reasonably well.
We experienced STA-MCA anastomosis in two cases of children with this disease.
Case 1 was a 23-months-old female with typical bilateral Moyamoya anomaly, for which she was done bilateral STA-MCA anastomoses. She was initially operated right side for completed stroke with moderate hemiplegia of the left face and extremities. Left STA-MCA anastomosis was done one month after the first surgery, because she got focal seizures on the right side followed by right postictal hemiplegia and aphasia for 4 hours. STA-MCA anastomosis was very effective, especially in right surgery for left completed stroke inducing rapid dramatic improvement of left hemiplegia. Angiographically, STAs were bilaterally patent two weeks after each surgery. Right surgery induced definite angiographical in-crease of cerebral circulation with dilatation of STA. Follow-up angiography revealed newly-formed vascular channels between dural arteries and cortical middle cerebral arteries with still patent anastomosis and further increase of circulation one year later. Only neuro-logical deficit of this patient is very slight restriction of fine movements of fingers of the left hand with increased deep tendon reflexes one year and seven months after surgery.
Case 2 was a 7-years-old school girl with stenosis of C₂ and C₁ of the right IC, right Al and right M₁, which was very much similar to the findings of Moyamoya disease except abnormal fine arterial networks of the base of the brain. Recurrent TTAs affected on the left extremities and face after crying required right STA-MCA anastomosis. However, C² of the right IC was occluded within two weeks after surgery with patent anastomosis. She had sensory TIAs affected on the left extremities a few times within a month postopera-tively. She has been free from TIAs or any neurological symptom for last 16 months after thelast attack. Right carotid angiography revealed widespread increase of cerebral circu-lation mainly due to newly-formed transdural anastomosis between branches of the middle meningeal artery and cortical middle cerebral arteries, even though STA-MCA anastomosis is still effectively patent one year after surgery.
As far as our operation is concerned, double anastomosis is a procedure of choice, because the stenotic trunk of the middle cerebral artery might restrict perfusion of blood within limited areas of anastomosed cortical branches of the middle cerebral artery. Al-though we did not perform encephalo-myo-synangiosis reported by Karasawa et al. (3), transdural anastomosis was developed remarkably in all cases with STA-MCA anastomosis. Preservation of the middle meningeal artery within an operative field seemed to be very important to produce transdural anastomosis.
Our experience indicates usefulness of STA-MCA anastomosis in the treatment of so-called “Moyamoya” disease, even if age of the patient is so young as 2-years-old.

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Although the etiology of moyamoya disease (MMD) is not known, treatments have been performed. The first was cervical carotid sympathectomy and superior cevical ganglio-nectomy(CCS and SCG)by SUZUKI et al. and the second was superficial temporal-middle cere-bral artery anastomosis (STA-MCA)and encephalo-myo synangiosis (EMS) by KRAYENBÜHL et al. We are presenting two cases of MMD (a 6-years-old girl of twins and 22-years-old women), who developed syndrome of cerebral ischemia, treated by bilateral STA-MCA and EMS, with good results.

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Wallenberg's syndrome is a classical syndrome and generally seen in lateral medullary infarction due to arterial occlusive lesion.
The author experienced seven cases of this syndrome.
Angiographic findings were occlusion of vertebral artery in four cases and abnormality of posterior inferior cerebellar artery in three cases.
There are variations in this syndrome and not a few cases are less severe or without showing full sings.
For the diagnosis of this syndrome it is necessary to remind of this syndrome when examine the patient comlaining of severe dizziness or vertigo, gait disturbance and dys-phagia. If not so, slihgt sings may be overlooked.
The author fears the possibility that some cases of this syndrome with mild attack or without showing full sings might be considered as dizziness or vertigo of unknown causes.

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