Electron microscopy has played an important role in the establishment of new tumor entities and diagnosis in brain tumor pathology. Although the introduction of immunohistochemistry has diminished the chances of ultra-structural analyses of brain tumors, electron microscopy is still an important and critical investigation method. Neuronal and glioneuronal tumors commonly possess dense core granules, clear vesicles, synapses, and neuritic processes containing microtubules. Ependymomas and choroids plexus tumors show epithelial characteristics, such as microvilli, cilia, juntional complexes, and basal lamina in addition to glial features. Most meningiomas show well- developed interdigitating cell processes which are connected by desmosomes. It is important not to interpret non-neoplastic, preexisting elements as neoplastic.

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The early diagnosis of patients with ischemic stroke is known to be important for both selecting the best therapy and for the patient's prognosis. Computed tomography is widely used as the first choice in detecting ischemic stroke and the early CT sign is used to diagnose super-acute cerebral infarction. However, it is reported that small infarctions and brain stem infarction of super-acute phase are difficult to diagnose by the early CT sign. From our experience, MRI can differentiate acute hematoma from acute infarction using DWI, and perfusion MRI is well correlated with perfusion sintigraphy by SPECT. We considered that MRI can be the first choice modality for acute ischemic stroke and useful to evaluate the existence of ischemic penumbra. Though MRI may be useful as the first choice modality for the patients with ischemic stroke, it is suggested that a more precise evaluation of ischemic penumbra is necessary and that a different technique such as MR spectroscopy should be evaluated on the basis of scientific evidence.

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Stroke is a medical emergency and time after onset is brain function. Therefore, it is essential to make every effort to develop all urgent correspondence full system for acute stroke. In 1997, NINDS (National Institute of Neurological Disorders and Stroke) presented the response time after the arrival of a stroke patient to a hospital by emergency, followed by AHA (American Heart Association) their a guideline 2000. The goal should be to (1) perform an initial patient evaluation within 10 minutes of arrival in the emergency department, (2) notify the stroke team within 15 minutes of arrival, (3) initiate a CT scan within 25 minutes of arrival, (4) interpret the CT scan within 45 minutes of arrival, (5) ensure a door-to-drug (needle) time of 60 minutes from arrival, and (6) transfer the patient to an inpatient setting within 3 hours of arrival. Should the patient meet the criteria for thrombolysis, quick access to stroke expertise within 15 minutes and to neurosurgical expertise within 2 hours of hospital arrival is recommended. Stroke patients have longer length of hospital stay. Stroke management is needed for the where team, (1) home doctor, (2) acute hospital, (3) rehabilitation hospital, and (4) care house. After the introduction of a clinical pathway dedicated for acute ischemic stroke of varying severity in 1995, the average length of hospital stay of both stroke and non-stroke patients declined in our hospital. Rehabilitation in the recovery stage can be done in the specialized rehabilitation hospitals within Kumamoto due to inter-hospital cooperation. Our acute stroke team can concentrate on the treatment of stroke in the acute stage (within 1〜4 weeks from the onset). We have been developing this stroke management system based on an acute stroke unit with referral to a rehabilitation unit in another hospital (inter-hospital referral model) in contrast to the conventional system with a combined acute and rehabilitation stroke unit in a single hospital (intra-hospital referral model). Eight-hundred and six patients (459 male, 347 female, 71.0 ± 12.2 years-old) with acute ischemic stroke were admitted to three hospitals between May 1999 and April 2000. The average NIHSS (National Institutes of Health Stroke Scale) was 8.2 (median 5). The length of hospital stay was 17.3 ± 17.4 (median 14) days. Two-fifth of all patients were discharged to their homes, and 76.6% of them were discharged within 14 days. Another 2/ 5 patients were transferred to rehabilitation hospitals, and 62.1% of them were discharged within 21 days. The reduction of length of hospital stay was achieved by the use of the clinical pathway and the inter-hospital cooperation.

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The medico-legal problems surrounding head injury cases are as follows : The pattern or scene of the receiving wound is reproduced, and information (material) to elucidate the whereabouts of the responsibility of victim's injury is offered. In other words, the medico-legal problem is in the elucidation of the legal causal relation. Information included here are not only the kind of the wound but also the apparatus which caused the wound, the type of impact, the mechanism of injury (blow, fall and fall down), the body situation when the wound was received (drinking, drug-intake and disease, etc.), and the state until dying after receiving the wound (level of consciousness and action ability). In fatal cases, elucidation of the cause of death is requested. In the mechanism of head injury, coup contusions are more easily caused than contre-coup contusions in blows and contre-coup contusions are more easily caused than coup contusions in falls and falling down. The apparatus which caused the wound can be judged according to the kind of wound surface. The level of drinking when wounded can be analyzed from not only blood and urine but also the intracranial hematoma. It is needless to say that the diagnosis of "Wound which can become cause of death" is the most important in the death example.

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Intraoperative aneurysmal rupture must be the most serious and stressful complication encountered in clipping surgery. Since the inappropriate management of this complication may lead to catastrophic results, it is required that surgeons acquire adequate skills and knowledge for handling intraoperative ruptures. First of all, excitement and haste seem to be the major causes of subsequent disaster. An excited mental state may cause finger tremor, and sometimes the surgeons may lose his cool judgment. An impatient surgeon will tend to use large and strong suction to aspirate the splashing blood promptly, which sometimes causes additional damage to the surounding tissue or even the avulsion of veins or perforators leading to catastrophic multiple bleeding. Such mental instability in the surgeon is mainly caused by anxiety that the encountered massive hemorrhage will ultimately lead to the patient's death. However, the rupture of a cerebral aneurysm is essentially the bleeding from the peripheral artery, and the loss of blood volume is usually not so massive as imagined. Thus, the surgeon should place the appropriate size suction tip to the pool of blood in a cool manner, being careful not to damage the surrounding tissue and therapy leading to additional bleeding points. When the bleeding point is securely observed, the temporary hemostasis should be obtained using a tentative clip. If exposure of the operative field is inadequate, the use of a temporary clip may also be another option of choice. After temporary hemostasis is obtained, the routine dissection is contined place the final clip to the appropriate position. In conclusion, meticulous observation of the bleeding point without haste is a shorter way to a favorable outcome, even in intraoperative rupture of cerebral aneurysms.

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Clinoidal meningioma has both a supra-and an infra-Willis portion at the advanced stage of its growth. Thetumor extends into the infra-Willis space either through the medial (medial-type) or the lateral window (lateral-type). The medial window is formed by the medial border of the internal carotid artery, the horizontal portion ofthe anterior cerebral artery, and the optic nerve. The lateral window is formed by the lateral border of the carotidartery and the tentorial edge. Medial-type clinoidal meningiomas form more complicated compartments than lateral types. These compartments are partitioned by the Willis' arterial ring, its branches, and the optic nerve. Thisunderstanding of compartment formation is important for surgical resection of the tumor to preserve encased cerebral arteries and their perforators. Through the supraorbital approach, the basal carotid artery is secured and thefeeding arteries are obliterated in the epidural, "Dolenc's triangle ". The tumor is resected in the order of one afteranother compartment, tracing encased cerebral arteries and their perforators, i.e. compartmental and artery-ori-ented resection. These techniques are also useful to reduce the risk of arterial injury even in difficult cases inwhich the tumor invades upon arterial adventitia.

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Hypopituitarism is a disease complex characterised by varying pituitary hormonal deficiencies. The aims of managing patients with hypopituitarism are to provide amelioration of the symptomatology associated with the con dition, to avoid potentially acute life-threatening complications and to protect against long-term sequelae including osteoporosis and cardiovascular disease. This is achieved through lifelong therapeutic replacement of target hormonal deficiencies, such as corticosteroids, thyroid hormones, or sex hormones, the general principle of replacing missing hormones are reviewed in this current paper. Moreover, to determine the effect of long-term hydrocortisone, thyroxine, and sex hormone treatment on quality-of-life (QOL) or metabolisms, we evaluated QOL, BMI (body mass index), serum lipid and glucose levels or bone density in 57 patients with panhypopituitarism. This study demonstrated that relative good QOL was maintained during long-term hormonal replacement therapy without growth hormone (GH) treatment, but these patients showed a tendency to increase the frequency of depression, hyperlipidemia, obesity, or osteoporosis, some of which were significantly improved after increasing thyroxine administration, but not changed after decreasing hydrocortisone administration. The precise underlying mechanisms responsible have not been fully elucidated, but probably include untreated GH deficiency as well as inappropriate or unphysiological replacement of other target hormones.

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