[in Japanese]

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We evaluated the treatment results of acoustic neuromas in the era of radiosurgery. We treated acoustic neuromas using the following strategy. Small to medium size tumors (below 3 cm) were treated by gamma knife radiosurgery and large tumors (above 3 cm) were treated using a combination of surgery and radiosurgery. Using gamma knife radiosurgery we were able to achieve 96.4% of clinical tumor growth control with 0.7% incidence of trigeminal neuropathy (without new facial neuropathy). We used low dose radiosurgery (average tumor marginal dose 11.8 Gy) with a follow-up of an average of 54 months. For the 17 patients with large tumors treated by the combination of surgery and radiosurgery who could be followed up for over 24 months after radiosurgery, we were able to preserve normal facial function (House-Brackmann grade I -II) in 70.6% of the patients after subtotal removal. High clinical tumor growth control for residual tumor was achieved in 94.1% of subjects with an average of 40 months follow-up. By using this strategy, the treatment outcome for acoustic neuroma is improved from the standpoint offunctional outcome and maintaining the patient's quality of life.

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Adenoid cystic carcinoma (ACC) is a malignant tumor which develops in the head and neck region. Occurrences in the orbit are relatively rare : they are mostly in the lacrimal gland. Therefore, the tumors develop in the superotemporal orbit. An 80-year-old woman was admitted to our department for left visual disturbance. Computed tomography (CT) and magnetic resonance (MR) imaging showed a mass in the medial region and apex of the orbita. Surgery was performed. Histopathological examination confirmed the diagnosis of ACC. The tumor was suspected to be derived from the invasion of an ethomoidal sinus tumor, the tumor from the ectopic lacrimal gland tissue.

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We report a case of cerebellar pleomorphic xanthoastrocytoma (PXA) with neuronal differentiation in an elderly patient. A 78-year-old woman was referred to our clinic because a solid mass with a cystic component was discovered in the right cerebellar hemisphere. Suboccipital craniotomy was performed and the mass was removed subtotally. Histopathological examination revealed a typical PXA with scattered cells that showed positive immunore-activity to synaptophysin and neurofilaments indicative of neuronal differentiation. Although PXA most commonly occurs supratentorially in children or young adults and its prognosis is believed to be relatively favorable, it should be included in the differential diagnosis of cerebellar neoplasms in elderly patients. Close monitoring is required to observe regrowth, especially in cases of PXA related to neuronal differentiation.

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We reported a case of true posterior communicating artery (Pcom) aneurysm, which was treated surgically after recanalization of Guglielmi Detachable Coils (GDC)embolization. A 51 year-old woman suffered sudden headache, and was admitted to our hospital immediately after onset. She had no neurological deficit apart from the headache (H-K grade I ). CT scans demonstrated a subarachnoid hemorrhage in the basal cisterns and right sylvian fissure. Cerebral angiography revealed a globular aneurysm with clear neck, arising from the right Pcom. An emergency GDC embolization was performed 6 hours after onset, resulting in almost complete occlusion of aneurysm. She was discharged on foot with mild feeling of weakness of the right upper and lower limbs. Follow-up angiogram obtained seven months later revealed recanalization and changes in the shape of the aneurysm. One year and five months later, neck clipping of the aneurysm via the right frontotemporal route was successfully performed. It was suggested that further GDC treatment or a surgical approach should be considered when follow-up angiogram revealed recanalization and changes in the shape of the aneurysm.

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A case of ruptured aneurysm in pregnancy treated by embolization is reported. A 27-year-old, previously healthy woman was admitted to her family hospital's obstetrics and gynecology department in the 28th week of gestation. She was sleepy and complained of headache and nausea. On admission to our hospital, her Glasgow coma scale was 12, but she had no neurological deficit. A computed tomography scan of the head revealed subarachnoid hemorrhage. Cerebral angiography showed a saccular aneurysm at the left vertebral-posterior inferior cerebellar artery junction. She was treated by endovascular approach with Guglielmi detachable coils. Successful maternal and fetal outcomes were achieved. After 35th week of gestation, she gave birth to a healthy infant by cesarean section. After 16th weeks' gestation, side effects for the fetus from radiation, iodized contrast material and general anesthesia are considered rare. Coil embolization of an aneurysm in pregnancy is the favorable method as is clipping.

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A case of multiple aneurysms at distal parts of the anterior inferior cerebellar artery (AICA) is reported. A 60-year-old woman, suffered sudden onset of headache and nausea and was diagnosed as having subarachnoid hemorrhage. CT scan revealed subarachnoid hemorrhage around the basal cistern. Left vertebral angiography showed two aneurysms at the right distal AICA, which originated from fenestrated basilar artery and fed an arteriovenous malformation (AVM) in the right cerebellar hemisphere. There were also a right middle cerebral artery aneurysm and a left internal carotid artery aneurysm. The AICA aneurysms were considered to be the cause of the subarachnoid hemorrhage and were occluded by endosaccular embolization with preservation of the AICA. The enlarged AICA made it easy to embolize the aneurysms, and the fenestration made it difficult to insert the microcatheter into the AICA. The multiple aneurysms were considered to be formed by factors related to congenital vascular anomaly and hemodynamic stress caused by the cerebellar AVM. To our knowledge, this is the first report of multiple distal AICA aneurysms treated by endosaccular embolization.

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A rare case of intravascular lymphomatosis is described. A 73-year-old man presented with dementia, memory disturbance, character change, right homonymous hemianopsia and cerebellar ataxia. FLAIR MRI scans demonstrated multiple hyper-intensity lesions localized at the right frontal lobe, the genu of the corpus callosum, the left occipital lobe and the cerebellum. A craniotomy for lesions of the left occipital lobe was performed and pathological examination revealed proliferation of large B-cells within small arteries using the immunohistochemical technique. Whole brain irradiation (2 Gy × 25 = 50 Gy) was performed immediately after the diagnosis, followed by combined chemotherapy (C-VEPA; Ara-C, vincristine, cyclophosphamide, prednisolone and Adryacin). Symptoms and radiological findings have been stable for 11 months since diagnosis. While prognosis depends on early diagnosis and treatment, the diagnosis of intravascular lymphomatosis is not easy. This disease should be considered when a patient presents with progressive changes of mental status and focal neurological deficits over a few weeks or months. FLAIR MRI scans may be especially useful for diagnosis.

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