The amount of scientific evidence regarding therapy for primary cases of glioblastoma and anaplastic astrocytoma is small compared with that for malignant tumors in other organs, and recommended therapeutic strategies derived from this evidence are not diverse. Evidence-based standard care of these tumors is very limited. At this moment, the benchmark treatment for these malignant gliomas is gross resection of the tumor bulk followed by local external beam radiotherapy (50-60 Gy) in combination with riitrosourea-based chemotherapy. Additional stereotactic radiosurgery or other strategies for localized therapeutic boosting have also been recommended. However, the clinical outcomes obtained through these standard treatments are unfortunately not always satisfactory. Novel therapeutic strategies for malignant gliomas are expected to develop and we hope that some scientific evidence would emerge from clinical trials using these novel strategies. New scientific evidence for practical and novel treatments appropriate for patients with malignant gliomas may come to be available as the evaluation of patients'quality of life is used as an end point for the analysis of clinical results, in addition to the commonly used survival analysis.

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Stroke is a leading cause of death and disability in Japan and primary and secondary prevention of this disastrous disease are unquestionablly important. Ultrasonographic assessment of carotid atherosclerosis is noninvasive and quite useful for evaluating not only the direct cause of stroke but also for predicting cardiovascular events in patients with risk factors such as hypertension, hypercholesterolemia, etc. In order to employ this carotid ultrasonographic evaluation for cardiovascular risk assessment, standerdization of the parameters reflecting the degree of carotid atherosclerosis is essential and such a guideline for the assessment of carotid atherosclerosis was reported in Neurosonology, official journal of the Japan Academy of Neurosonology in 2002. Here, the essence of this report was introduced and the importance of employing the common carotid far wall maximum intima-media thickness (IMT-Cmax) as standard index reflecting cardiovascular risk is stressed.

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In this report, we describe our experience on the treatment of CTS. Patients and Methods : 187 operations were performed in 45 males (56 operations) and 110 females (131 operations) for CTS during the period from January 1995 to December 2001 in our hospital. The results of surgical treatment were retrospectively reviewed. Before operation, a neurophysiologic examination was performed in all patients. In all patients, standard open release of the carpal tunnel was performed. Results : The outcome was graded as "excellent" in 169 operations, as "good" in 12 operations and "poor" in 6 operations. Twelve out of 187 were reoperations. Six out of the 12 re-operated patients had received their first operation in other hospitals. These patients all had minimal incision without endoscope for carpal tunnel release. Among 6 re-operated patients who had received the first operation in our hospital, 1 patient had work-related CTS, 2 suffered from hyperuricemia, 2 had incomplete exposure and 1 had a wound hematoma. Twenty patients had bilateral CTS and required two procedures. In the case of CTS complicated with a basic disease or work-related factors, minimal incision for carpal tunnel release (MICTR) should not be done. In spite of open release of carpal tunnel (OCTR) being performed as the first operation, an incomplete exposure should be reconsidered.

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Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive tool and has been effectively used for the treatment of neurological disorders. This study was conducted to clarify whether or not rTMS can improve neurological status in patients with prolonged consciousness disturbance by examining changes in the cerebral blood flow (CBF) and the cathecholamine metabolites in the cerebrospinal fluid (CSF). We examined 13 patients who suffered from prolonged (more than 45 days after the ictus) impaired consciousness. The rTMS was applied at medium energy capacity and 0.5 Hz for 10 minutes. Before and after the rTMS, concentrations of cathecholamine and cathecholamine metabolites (epinephrine, norepinephrine, dopamine, 5-hydroxy-3-indole acid, homovanilicacid and 3,4-dihydroxyphenyl acetic acid) in the CSF were determined using HPLC and the CBF values were determined using the ^<99m>Tc-ECD Patlak plot method. The rTMS increased the CBF values in the unaffected hemisphere and the dopamine concentration in the CSF in a group of patients showing an improvement of their consciousness disturbance. The application of rTMS is a potential therapeutic tool for patients with prolonged consciousness disturbance. rTMS is also a useful diagnostic procedure to evaluate and predict the outcome in patients with consciousness disturbance.

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A 42-year-old man was incidentally found to have swelling of the thyroid gland during a medical examination. On his endocrinological studies, the level of serum free T3, free T4 and TSH were elevated. TSH reacted to neither TRH nor free T3. MRI revealed an intra and supra -sellar enhanced tumor and plain CT showed that the tumor was partly surrounded by capsular calcification. Surgery was performed twice at the 3-weeks interval by the transsphenoidal route, and the tumor was totally removed except for the capsular calcification. Immunohistochemical examination showed positive staining for TSH, and FSH and GH at part. Pathological diagnosis was TSH secreting pituitary adenoma. TSH secreting pituitary adenomas with calcification are rare, and there have been only 6 cases reported including ours. We discuss the clinical charactaristics and surgical strategy of this particular adenoma.

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We present a case of a 27-year-old female with obstructive hydrocephalus due to aqueductal stenosis. On August in 1988, she was treated for germinoma with surgical partial resection and radiation (whole cranial 50 Gy). She was cured and had no tumor recurrence. On February in 2003, her activity of daily life was decreased, and CT and MRI disclosed segmental occlusion or severe stenosis of aqueduct with hydrocephalus. Endoscopic third ventriculostomy was performed on March in 2003. After surgery, her activity of daily life improved. In operative view by neuroendoscope, an old bleeding point at the aqueduct neighbor was discovered, and a blood clot was obstructing the flow of cerebrospinal fluid.

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A case of acute spontaneous subdural hematoma with angiographic extravasation of contrast medium is reported. A 56-year-old man was admitted because he experienced a sudden severe headache, vomiting and a disturbance of consciousness while washing his car. He had no experience of head injury. On admission, computed tomography (CT) revealed an acute subdural hematoma in the right temporoparietal region. Cerebral angiography showed an extravasation of contrast medium from a branch of the angular artery at the edge of the hematoma. After these examinations, the hematoma volume showed no further enlargement and his neurological symptoms improved. Therefore, he was observed under conservative therapy. Twenty days after onset, hematoma evacuation with right craniotomy was performed because he complained of a headache and his CT demonstrated chronic subdural hematoma. During operation, bleeding from the cortical branch of the angular artery was found and it was coagulated. He was discharged after 37 days without any neurological deficit. The characteristic features of acute spontaneous subdural hematoma were retrospectively investigated in the literatures. Acute subdural hematoma with an unknown history of head injury should be treated in consideration of possible spontaneous subdural hematoma.

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We present a case of acute focal demyelinating lesion in the left temporal lobe mimicking a malignant brain tumor. A 34-year-old man suffered from sensory aphasia. Magnetic resonance imaging (MRI) showed a mass lesion in the left temporal lobe with incomplete ring-like enhancement by gadolinium. The patient underwent a partial resection of the lesion. Intraoperative pathological diagnosis was astrocytoma (grade II). However, postoperative MRI demonstrated that the residual lesion decreased in size and pathological studies revealed a demyelinating lesion without neoplastic change. The difficulty of differential diagnosis between demyelinating disease as a solitary contrast-enhancing mass and malignant brain tumor is discussed based on both the neuroimaging and neuropathological aspects.

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