Treatment of acute cerebral infarction has come to be considered as a brain attack with the development of rt-PA. However, the use of rt-PA for cerebral infarction is not permitted in Japan. The number of stroke patients who could be treated with rt-PA is estimated at 10,000 per year. The results of our JSSR (Japan Standard Stroke Resistry) study suggest that intra-arterial therapy with rt-PA/UK is more effective than conventional therapy in moderate to severe patients. The time limit for rt-PA should be more flexible in advanced strokes, especially basilar artery thrombosis. When rt-PA is permitted as a treatment of acute cerebral infarction, combined therapy with free radical scavenger should be useful.

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The unruptured Cerebral Aneurysm Study in Japan (UCAS Japan) is being conducted to build a Japanese data bank of unruptured cerebral aneurysms (UCA). The goals of this study are to identify the natural course and treatment risks of such aneurysms. This is a prospective cohort study and enrolled patients are cases with newly diagnosed UCA after January 1,2001. Tentatively, new patient entries are scheduled until the end of 2003. The data of all patients with UCA, either treated or observed, are stored in a head-quarters computer through internet registration. All cases are scheduled to have periodic follow-up at 3 months, 12 months and 36 months after diagnosis. Registered data include a patient's demographics (other than privacy information) , neurological status, past and family history, and aneurysmal characteristics. During the last 8 months, we have collected data on 1,378 new patients (1,671 aneurysms) with UCA registered from 350 institutions. So far, there is a difference in registry status between geographic locations in Japan. The male-female ratio is 1 : 2 and the median age of patients is 64 years (range 20-91). The size of aneurysms ranged from 3-45mm (median of 5mm). The most frequent reason in finding UCA has been ill-defined symptoms such as headache or dizziness. Multiple aneurysms has been found in 18% of cases and 96% of aneurysms has been saccular ones. At the first registration, craniotomy was indicated in 30% of cases and endovascular treatment in 4% of cases. Fifty three percent of cases were observed without intervention. Three months of follow-up has been reported in 673 cases so far. Treatment has been performed in 230 cases with 245 aneurysms. The detailed protocol for this study can be reviewed at https: //endai.umin.ac.jp/islet/ucasj/. We are planning to call for further patient enrollment and conform reliable data to direct future management of UCA.

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Rebleeding is the most powerful prognostic factor in vertebrobasilar arterial dissections presenting with sub-arachnoid hemorrhage. This study was conducted to elucidate the factors related to the rebleeding. Among 95 patients with intracranial arterial dissection of the vertebrobasilar system, 64 presented with sub-arachnoid hemorrhage. The rebleeding occurred in 20 patients (31%). The clinical and radiological factors in the rebleeding group were compared with those in the non-rebleeding group. A logistic regression analysis was used for statistical analysis. Results : 1) Age, gender, and location of arterial dissection did not differ between the rebleeding and the non-rebleeding group. 2) History of arterial hypertension, a poor Hunt and Kosnik grade, and pearl and string sign as an angiographical finding were significantly more common in the rebleeding group, independently. These results were confirmed in both the univariate and the multivariate analyses. 3) The outcome was significantly unfavorable in the rebleeding group. These data suggested that a history of arterial hypertension, a poor Hunt and Kosnik grade, and the angiographic presence of pearl and string sign might be the significant factors related to rebleeding.

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A 15-year-old female presented with a 10-month history of generalized epileptic activity. Neurological and neuropsychological examination revealed no abnormalities. Magnetic resonance imaging (MRI) demonstrated a slightly enhanced round expansive tumor, which appeared identical on both T1- and T2-weighted imaging, in the left precentral gyrus medial to the precentral knob. Magnetoencephalography, functional MRI, surface anatomy scan with venography, and fiber mapping using diffusion-weighted MRI disclosed that the tumor was located just before the leg motor cortex and had displaced the corticospinal tract posterolaterally. Surgery was performed with the patient under general anesthesia. Stimulation mapping techniques for localization of the motor cortex and the descending motor pathway was applied under guidance from a neuronavigation system. Direct cortical stimulation of the anterior half of the precentral gyrus overlying the tumor did not evoke leg motor movements. Thus, the cortex was resected up to the location of the leg motor cortex confirmed by the direct cortical stimulation technique. The tumor was completely resected with preservation of the descending motor pathway. The histological diagnosis was ganglioglioma. Postoperatively, the patient only had transient weakness of the right leg, and was discharged home 11 days after the operation without neurological deficit. The whole of the precentral gyrus does not correspond to primary motor area (area 4). If the patient has no neurological deficit and the tumor has an expansive nature, as evaluated by MR imaging, gliomas at the anterior side of the precentral gyrus can be resected without permanent motor deficit.

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A 70-year-old woman suffering from a subarachnoid hemorrhage (SAH) was transferred to our hospital. Three-dimensional CT angiography (3D-CTA) demonstrated an anterior communicating artery (AcomA) aneurysm. One day after the onset of the SAH, surgery was performed. Intraoperative findings revealed an unexpected situation : the AcomA complex was encased in a small meningioma of the tuberculum sellae. A piecemeal removal of the tumor was perfomed with CUSA in a careful manner. However, the aneurysm accidentally ruptured during the dissection of the aneurysmal complex. Temporary clips were applied to the bilateral Al arteries and then complete neck clipping was carried out. Her postoperative course was uneventful. An aneurysm encased in a meningioma is very rare. In these cases, the surgical strategy may be complicated. A 3D-CTA can be useful for surgical planning.

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The authors report a rare case of expanding cavum septi pellucidi (CSP) occuring in a 65-year-old man secondary to obstructive hydrocephalus, bacterial meningitis and ventriculo-peritoneal shunt procedure. Preoperative perfusion MRI demonstrated hypoperfusion of the corpus callosum, and we subsequently performed endoscopic transventricular fenestration of the cystic CSP. Intraoperative neuroendoscopic observation using rigid endoscope revealed that the medial wall of the lateral ventricle protected and was pulsing, but the foramen of Monro was not obstructed. The expanding CSP wall was fenestrated and biopsied and communicated within the ventricular systems using a 4mm-steerable fiberscope, and confirmed the abscence of abnormal structures within CSP cavity. Postoperatively, the CSP was collapsed to a normal size and improvement of the regional blood flow of the corpus callosum was confirmed. Histological study of CSP wall revealed massive gliosis with perivascular accumulation of inflammatory cells. We consider that this was an aquired cyst of the CSP, which expanded due to check valve mechanism between the lateral ventricle and the wall of CSP, and emphasize the efficacy of neuroendoscopic strategy for symptomatic CSP.

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Surgical management of ossification of the cervical anterior longitudinal ligament (OALL) associated with ossification of the cervical posterior longitudinal ligament (OPLL) was reported. A 83-year-old man was admitted to our hospital complaining of dysphagia and moderate myelopathy. Imaging studies, including esophagoscopy, revealed marked esophageal compression due to OALL that extended C2-C6 levels and OPLL (C4-C5 level) that compressed the cervical spinal cord. In anterior approach, the use of rongeurs and a high-speed drill facilitated excision of OALL and trans-vertebral anterior decompression without fusion was performed for the resection of OPLL. Postoperatively, patient's dysphagia and symptoms of myelopathy immediately resolved. Patients with dysphagia and coexisting myelopathy benefit from simultaneous surgery for resection of GALL and OPLL by anterior approach.

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A case of intracerebral pneumocephalus due to head injury is reported and reports of this rare state are reviewed. These cases are relatively rare and only 13 cases including the present case have been reported to date. In this case, magnetic resonance imaging (MRI) clearly demonstrated not only the accumulation of air but also the herniation of brain tissue through fracture into the frontal sinus. Surgery for repairing the skull base fracture led to successful recovery without complications such as meningitis or delayed brain abscess. The diagnostic evaluations and surgical treatments of these cases are discussed.

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We report two cases of aberrant right subclavian artery (ARSCA) found by transbrachial cerebral angiography. ARSCA originates from the descending aorta, distal to the left subclavian artery, with a reported incidence of 0.4 to 2%. In our hospital, ARSCA was found in 0.16% of all cases in which transbrachial cerebral angiography was performed in the last 6 years. In performing cerebral angiography from the right brachial artery, this anomaly should be considered when a catheter will go only into the descending aorta.

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