Lacunar infarction, leukoaraiosis, etat crible and cerebral atrophy increase in incidence and severity with age. They are believed to be essentially "asymptomatic", when observed in aged subjects, who are free of serious neurological symptoms. To assess the influences of these cerebral lesions on cognitive functions in the aged subjects, we evaluated MRI findings and the Hamamatsu psychological battery for higher cerebral function. Out of 127 participants in the present study, 42(33.1%)showed mild to severe impaired cognitive function. Leukoaraiosis(β=0.267, p=0.014)and cerebral atrophy(β=0.182, p=0.038)correlated well with the impairment, whereas lacunar infarction and etat crible seemed to have no effects on cognitive function. Adequate control of risk factors for leukoaraiosis and cerebral atrophy might prevent cognitive impairment.

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Clinical results of our experience on stenting for extracranial carotid stenosis are reported. The subjects were 87 lesions(85 patients)of severe stenosis of the extracranial carotid artery treated with stenting between August 1997 and March 2000. Subjects consisted mainly of patients excluded from carotid endarterectomy according to the criteria of NASCET and ACAS : elderly patients, patients with severe cardiopulmonary complications, patients with contralateral occlusion or severe stenosis, patients with concomitant tandem lesions, and restenosis after carotid endarterectomy. The technical success rate was 85/87(97.7%), and all the successful cases showed sufficient patency rates(80% or more). Rate of complications were 2.3% for permanent deficits(severe cerebral infarction, 1 ; mild cerebral infarction, 1), and 8.0% for temporary deficits(TIA, 4 ; RIND, 3), and most of them were experienced in the first half experience. Based on these, we focused on 1)evaluating the plaque property during determination of indications, 2)introducing a distal protective balloon, and 3)avoiding unreasonable complete dilatation. These modifications provided significant reduction in complication rate. Stenting for extracranial carotid artery stenosis is considered a promising less invasive treatment for occlusive cerebrovascular diseases in the aging society. However, there are many problems to be solved : establishment of its significance in stroke prevention including a long-term outcome, development of stents suitable for the cervical carotid artery and effective protective systems for distal thromboembolism, and measures against restenosis.

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We had 6 cases pituitary abscess since 1980 and analyzed the clinical feature of this rare entity in this study. Between 1980 and 2000, we had 465 cases with parasellar tumors. All the cases were treated surgically and diagnosis was made by histopathology. There were 6 cases of pituitary abscess. Two were male and 4 were female with an average age at 36.3-year-old. Chief complaints were bilateral hemianopsia in 5 cases and headache and high fever in one. Endocrinological dysfunction of pituitary was found in 3 cases. The duration from the onset of symptom to preoperative diagnosis ranged from 20 days to 8 months with an average of 4.4 months. The cause of abscess was meningitis in 2 cases, postoperative infection with pituitary adenoma in 1 case, sphenoid sinutitis in 1 case and unknown in the remaining 2 cases. For the surgical treatment, transsphenoidal approach was chosen in 3 cases and transcranial approach in 3 cases. The confirmation of microorganism was obtained only in 1 case and the other 5 cases resulted in negative. The neurological deficit was all recovery postoperatively, but the endocrinopathy demonstrated no recovery. The follow-up period ranged from 1 year to 16 years with an average of 11.1 years. The recurrence was not observed in any case. The mortality with pituitary abscess was high in the past decades but recent advancement of the treatment of infection enabled us to obtain no mortality as demonstrated in the present study. Hoevever, the endocrinopathy due to inflammation on pituitary gland was irreversible, despite of that the neurological deficits caused by mass were well recovered. To improve the functional outcome with pituitary abscess, careful preoperative diagnosis and early surgical treatment are recommended.

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We report a case of a ruptured accessory anterior cerebral artery(AccACA)aneurysm in a 59-year-old man suffering from intracerebral hemorrhage in the corpus callosum. Angiography showed both a triple A2 segment of anterior cerebral artery(ACA)and a saccular aneurysm at the bifurcation of the AccACA. The aneurysm was clipped by direct surgery and he was discharged without neurological deficit. AccACAs in themselves are not so rare, but aneurysmal formation in such cases is extremely rare. In introducing this case, we discuss AccACAs and AccACA aneurysms.

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Retroperitoneal hemorrhage is often life-threatening. Pelvic fracture is well known as a major cause of retroperitoneal hemorrhage, but instances caused by lumbar arterial injury are extreamly rare. A 56-year-old man who sustained hemorrhagic shock associated with lumbar and pelvic fracture was admitted. His blood pressure gradually fell in spite of the administration of crystalloid and electrolyte solution. Abdominal CT scans showed retroperitoneal hematoma. Extravasation of the second and third lumbar arterial branches were observed on abdominal aortography. Selective lumbar arteriography was performed, and the injured vessels were embolized with sponsels and coils. Embolization was effective in controlling hemorrhage from the lumbar arteries.

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We reported a case in which a new preliminary treatment trial was performed successfully by chemotherapy using anti-cancer drugs selected on the basis of multidrug resistance gene mRNA expression from RT-PCR assay. A 74-year-old female had gradually developed right hemiparesis. A CT scan revealed 2 homogeneously enhanced tumors, one in the left frontal and one in the left thalamic-peduncular areas. Biopsy of tumor in the left frontal lobe revealed a diffuse large B-cell lymphoma. Tumor tissue was examined for the expression of multidrug resistance gene mRNA such as MDR1, MRP1, cMOAT/MRP2, MXR1, MGMT and Topo IIα using RT-PCR assay. The examination revealed overexpression of MDR1, MRP1, MGMT and Topo IIα mRNA, but neither cMOAT/MRP2 nor MXR1 was expressed. First the patient was given a high-dose(3.5g/m^2)of methotrexate(MTX), and then the tumor in the left frontal lobe disappeared on a CT after 1 course of chemotherapy. However, the other tumor, in the left thalamic-peduncular region, showed regrowth after once disappearing. The patient was given successfully carboplatin(400mg/m^2), mitoxantrone(10mg/m^2), and prednisolone(60mg/m^2)with high dose MTX on the 2nd and 3rd courses of chemotherapy without irradiation. MR imaging after chemotherapy showed the complete disappearance of both tumors. After this the patient was discharged with a mild right hemiparesis.

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We present a case with a persistent primitive trigeminal artery(PPTA)which was revealed incidentally on angiography for transient ischemic attacks. A 68-year-old man with loss of right visual acuity presented a 3-month history of temporary attacks of right arm weakness and speech disturbance. CT scan in another hospital had incidentally revealed a tumor in the right cavernous sinus. The patient was admitted to our hospital for further examination. Left carotid angiography(CAG)showed 90% stenosis of the cervical internal carotid artery and delayed filling into the ipsilateral middle cerebral artery(MCA)territory. Left vertebral angiography(VAG)demonstrated normal appearance of left vertebral artery and basilar artery, and reverse flow through a small PPTA and a posterior communicating artery filling the carotid siphon and MCA territory. The patient underwent carotid endarterectomy(CEA)without any complications. Left CAG after CEA showed disappearance of the carotid stenosis and blood flow through a PPTA into the posterior circulation system. The PPTA was not demonstrated on left VAG. The transient ischemic attacks in the present case were due to microemboli originating from carotid atherosclerotic plaque. It should be kept in mind that the direction of the blood flow through a PPTA in association with the severe carotid stenosis can be reversed before and after CEA.

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Persistent primitive hypoglossal artery(PPHA)is frequently associated with an intracranial aneurysm as previously reported. We report here our experience with a case of PPHA associated with multiple cerebral aneurysms. A 59-year-old woman was brought to our hospital suffering from severe headache and vomitting. A subarachnoid hemorrhage(SAH), which was classified as Fisher group 2, was confirmed by CT scan. Cerebral angiography revealed the two aneurysms, one located at the anterior communicating artery and the other at the top of the basilar artery, a right persistent primitive hypoglossal artery was identified. The right vertebral artery was aplastic, and the left vertebral artery was hypoplastic. A diagnosis of SAH(Hunt & Kosnik Grade II)due to a ruptured anterior communicating artery aneurysm was made and an operation was performed at day 4, comprising a right frontotemporal craniotomy and an anterior clinoidectomy. Both aneurysms were treated by neck clipping through the pterional approach with no intraoperative trouble. Postoperative course was uneventful, and 3D-CTA was available with the diagnosis of PPHA. The second angiography was carried out at day 14, and revealed that both aneurysms were completerly clipped. The patient was discharged with no neurological deficits. It was suggested that a congenital fragility of the vessel wall, in addition to hemodynamic stress and hypertension, had influence on the etiology of this aneurysm associated with PPHA

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Spontaneous spinal epidural hematomas are uncommon and are especially rare when the lesion involves more than 8 vertebral segments. We report a rare case of spontaneous spinal epidural hematoma extended to 14 vertebral segments, and discuss treatment with a review of the literature. A 78 year-old-woman was presented with sudden onset of paraplegia and severe back pain. Emergent spinal MRI showed that an epidural hematoma extended from C7 to L1. The hematoma was evacuated immediately through T9-T11 laminectomy followed by epidural drainage. Her symptom recovered rapidly, and MRI at 5 days after the operation showed the complete disappearance of residual hematoma. We suppose that localized laminectomy and epidural drainage following an early diagnosis are effective for long extended spinal epidural hematomas.

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We report herein a rare case of undifferentiated glial tumor suspected to have developed from the oculomotor nerve. A 9-year-old boy complained of ptosis on the right side and diplopia. MRI revealed a mass in the basal cistern. Total resection was performed by a right subtemporal approach and operative findings suggested that the tumor originated from the oculomotor nerve. We suspected that the tumor originated from the peripheral nerve, however, pathological findings were atypical and a working diagnosis of undifferentiated glial tumor was given. Aside from complete right oculomotor nerve palsy, the patient recovered well. Postoperative MRI revealed no residual tumor. Six weeks after surgery, he suffered from progressive symptoms of nausea, vomiting, headache and lumbago. MRI revealed that rapid regrowth of the tumor had invaded the mid brain, bilateral cerebello-pontine angle and temporal lobe. Deterioration was rapid, and he died 10 weeks after surgery. An autopsy was not performed. There have been no previous reports of glial tumor arising from the peripheral nerve other than Reifenberger's report of a primary glioblastoma multiforme of the oculomotor nerve. It was suspected that the tumor originated from glial cells within the most proximal part of the nerves. In our case, the tumor was located further from the brain stem. However, we suspect that the tumor may indeed have originated from glial cells within the most proximal part of the oculomotor verve, the heterotopic glial tissue in the oculomotor nerve, or was an invasion from a brain stem glioma.

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