In the medical field, an important problem facing modern surgical staffs is how the safety of the surgery is ensured. The surgeon visualizes the anatomy in the preoperative CT/MR image, and the surgical approach is planned. Simultaneously, he confirms distribution of the functional location even in the functional MR images and the neurophysiological examination. The neurosurgeon then acquires the intraoperative MR images of brain shift and tries to remove the tumor maximally while the functional region of eloquent area is identified. Our final goal is to remove the brain tumor totally. Our surgical staff visualize the brain tumor in order to achieve the goal, and the brain tumor is removed maximally. However, the necessary cerebral function in the eloquent areas must also be retained.

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The first authorized human gene therapy was performed in the United States in 1990 on a patient with a defective adenosine deaminase (ADA) gene. Since this successful treatment, a variety of human gene therapy protocols have occurred worldwide. At present, more than 3,000 patients are enrolled in more than 500 protocols. Target diseases for gene therapy are expanding to encompass aquired life-threatening diseases such as cancer. As for brain tumors, especially for malignant gliomas, two major gene therapy approaches have been applied; 1. Suicide gene therapy using the herpes simplex virus thymidine kinase (HSV-tk) gene and ganciclovir, and 2. Immune gene therapy using cytokine genes. In the case of immune gene therapy, our team of neurosurgeons at Nagoya University developed a new form of treatment using the cationic liposome entrapped human interferon-beta gene, and use of this clinical protocol commenced in April, 2000.

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Extensive surgical removal of brain tumors to achieve an adequate safety margin is usually impossible because such extensive removal carries the risk of additional morbidity. Therefore, debulking of the tumor followed by adjuvant therapy has become the standard treatment for glioma. However, the rate of tumor removal remains the most important factor for the outcome, so as much tumor as possible must be removed without causing morbidity, even if the glioma is located near eloquent areas. Intraoperative functional brain mapping and monitoring, and preoperative functional mapping by magnetoen-cephalography (MEG) are methods for the prevention of morbidity. These techniques can provide important information about tumor localization and the relationship with the surrounding eloquent areas. Of course, excellent surgical technique remains critical for achieving an acceptable outcome in addition to the mapping and monitoring techniques. We have developed a new surgical technique combining sulcotomy and gyrectomy for the treatment of glioma. Glioma usually originates from the subcortex in one gyrus and invades the deep white matter. Therefore, the gyrus harboring the tumor can be separated from the eloquent area in the sulcus at least on the cortical level. We describe this surgical technique as applied to intraaxial lesions.

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A nine-year-old girl with papillary meningioma in the left parietal convexity is reported. The initial size of the tumor was 6 cm in diameter and surgically removed completely. Since then, the tumor repeated recurrences six times in six years and she was surgically treated for each time. Pathological studies of each specimen resulted in papillary meningioma with typical formation of lumens by papillary cells associated with wheel formation by spindle-shape cells. MIB-1 immunohistochemistry for each specimen demonstrated initially low index at 0.4 however, the index progressively became high up to 17.5 at the sixth time. Subcutaneous tumor metastasis at the site of scalp skin flap was also recognized three times, which were surgically removed. Papillary meningioma is a rare subtype of meningioma that is categorized as grade III in WHO classification and thought to be relatively malignant in nature. The value of the MIB-1 index to predict the recurrence of tumor in benign meningioma has been well recognized. In papillary meningiomas, the risk of recurrence should be always considered regardless to the MIB- 1 index value.

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A 58-year-old woman with progressive disturbance of consciousness was admitted to our hospital. CT scans and MR images revealed a large tumor expanded to the bilateral anterior cranial fossae. The tumor was composed of two components. One containing the falx in the mid portion was expanded to the left anterior cranial fossa with calcification inside, and the other occupied the right anterior cranial fossa including some cysts. Pathological study showed fibrous meningioma (WHO grade I ) in the left component, and atypical meningioma (WHO grade II) with mitosis in the right component. It was considered to be a case of large falx meningioma, which grew rapidly with a partial malignant transformation.

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We report a case of a subacute expanding intracerebral hematoma associated with a cavernous angioma. A 68-year-old man was presented with transient unconsciousness. He had a past history of mild thrombocytopenia, which was suspected to be ITP (idiopathic thrombocytopenic purpura). Computed tomography (CT) showed right frontal subcortical hemorrhage (2 cm). Repeated CT revealed a gradual enlargement of the hematoma with an eccentric high intensity area. The hematoma had grown up to 6 cm in diameter when the patient showed disorientation. On the 17th day from the onset, the operation was performed and a liquefied intracerebral hematoma with no capsule and a hemorrhagic mural mass were removed. The pathological finding of the mass was a cavernous angioma. It is a rare case that a continuous enlargement of the hematoma after the initial bleeding from the cavernous angioma was followed by CT scan. In this case, mild thrombocytopenia might be one of the causes of the initial overt hemorrhage and the following enlargement of the hematoma.

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A 59-year-old man presented with a sudden right-side neck pain. There were no obvious abnormalities detected on the first CT scan. About 35 hours after the first episode of neck pain, however, he was admitted after being diagnosed with subarachnoid hemorrhage. Cerebral angiography demonstrated characteristic pearl and string sign in the right vertebral artery involving the posterior inferior cerebellar artery. Serial angiography showed an increase in the size of the aneurysm. Proximal occlusion of the right vertebral artery was performed using detachable coils on the 23rd day after the admission. Postoperative course was uneventful and a reduction in the size of the aneurysm was noted during the follow-up period.

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A 55-year-old female was admitted to our hospital at 6:16 a.m.. She was found comatous on her back outside of her apartment. She was drinking alcohol until 4 a.m.. A bruise was found only on her right occipital scalp. Plain X-rays of the skull showed linear fracture in the right occipital bone. A computed tomography (CT) scan performed about 1 hour after arrival revealed epidural hematomas in the right occipital and bifrontal region. Initially, an occipital craniotomy was performed and the hematoma was removed. The origin of bleeding was a small meningeal artery (a dural branch of the occipital artery). Thereafter, the position was changed, and bilateral frontal epidural hematoma removal and hemostasis was done. The superior sagittal sinus was the origin of bleeding in the frontal hematoma. The postoperative course was uneventful. She was discharged free of neurological symptoms after 17 days of hospitalization. We assume contrecoup acute epidural hematoma to be rare as we have found only four reports in the literature so far.

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