By the fiduciary relationship between patient and doctor, medical treatments were originally carried out and the treatments selected under the autonomy of the doctor. However, there is currently far greater interest in EBM and standard medical treatment not only amongst medical professionals but also amongst the general public, due to both a mass medua inspired mistrust of the medical practice in general and recent politically mandated health expenditure reductions. In comparison with medical treatment which uses a homogeneous object to be the material used by a homogeneous method (medicine), the preparation of the standard treatment in the surgical field is very difficult because the operation is the art and the materials are heterogeneous. In this paper, the difficulty of standard medical treatment preparation in the surgical field is described, while the definition and the significance of EBM, de dure standard, and standard medical guidelines, which are often misunderstood, are explained.

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In the management of small vestibular schwannomas, we have nowadays three therapeutic options available such as conservative management, stereotactic radiosurgery, and microsurgical tumor removal. Accordingly, we must have correct knowledge about the natural history of this kind of tumor. Therfore, a review from the literature is presented here. Annual growth is reported as 1〜2mm/year. About 30〜70% of the tumors do not change and 5〜20% do shrink during an observation period of a few years. Hearing function is getting worsening irrespective of the tumor growth. It is considered generally that microsurgical removal has an advantage in radicality and stereotactic radiosurgery is preferred in hearing preservation and for its less invasive character.

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The meninges (dura mater, arachnoid, pia mater) are the site of numerous pathological lesions including inflammation and neoplasm. Meningiomas are the most frequently observed lesions and the most common of primary meningeal tumors. Over the years, meningiomas have been histologically classified and some entities have been added to the cadre of meningioma variants, while others have been designated as other types and tumors. The 2,000 revision of the WHO system provided diagnostic guidelines. Most meningiomas are biologically benign and correspond to WHO grade I. However, certain meningiomas have an increased tendency to recur or follow an aggressive clinical behavior and are assigned to WHO grade II and III. Atypical meningioma, clear cell meningioma and chordoid meningioma, corresponding to WHO grade II, have a substantially increased incidence of recurrence. Rhabdoid meningioma, papillary meningioma and anaplastic meningioma, corresponding to WHO grade III, have an even higher incidence of recurrence and may be associated with systemic metastasis or brain invasion.

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Although therapeutic protocols involving high-dose MTX yield relatively favorable results against primary central nervous system malignant lymphoma, it is still rare for this type of tumor to be cured by this approach. Recently, new protocols and guidelines for refractory or relapsed primary CNS lymphomas were reported. These protocols include repeated high-dose MTX therapy, salvage therapy with temozolomide or topotecan, intraventricular treatment with rituximab, and clinical practice guidelines in oncology-v. 1. 2004, NCCN. Under these circumstances, we evaluated the efficacy of stereotactic radiosurgery administered as an additional therapy in cases with partial remission or recurrent cases of this tumor. Forty two patients were initially treated at our facility by chemotherapy with MTX followed by whole-brain irradiation. Of these, 7 patients who had shown partial remission after initial treatment and 7 other patients who had developed tumor recurrence during follow-up received regional stereotactic radiosurgery. The mean survival period after tumor recurrence was 27 months. When the outcomes of the 42 patients were analyzed, the median survival period after the start of initial treatment was extended to 64 months. These results indicate that stereotactic radiosurgery is useful for treating malignant lymphoma of the CNS where the disease remains unremitting or has recurred after initial treatment.

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We described the clinical application of a handmade titanium plate for reconstruction of the cranial vault in three cases of postoperative complicated bone defects. The titanium plate was modeled and trimmed after the excised bone flap, or after the reconstructed bone made by joining the fragmented pieces in case of complicated skull fractures. It was made in one or two days, and at low cost. And satisfactory shaping was obtained despite the complicated defect of the cranial vault. Neither infection nor local abnormalities were revealed after cranioplasty. We conclude that the above mentioned method is useful for reconstructing postoperative skull defects with lower costs.

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Intracranial dural arteriovenous fistula presenting with progressive myelopathy is uncommon and such cases have been rarely reported in the literature. It is also difficult to accurately diagnose intracranial fistula in such cases, because the patient only demonstrates symptoms of myelopathy. We recently experienced such a rare case. A 61-year-old man presented with repeated episodes of ameliorable weakness in both lower limbs for a few days. At the same time numbness of both hands, dysuria and constipation occurred. Three months before presentation, motor weakness of both lower limbs again occurred associated with a progressive gait disturbance. As a result, he was referred to our hospital under a diagnosis of a spinal vascular malformation. After performing MRI, 3D-MRA and angiography, a dural arterovenous fistula of the transverse-sigmoid junction was demonstrated, which drained into the spinal cord vein via the superior petrosal sinus and perimedullary vein associated with venous hypertension. Transvenous embolization to the superior petrosal sinus was therefore performed to prevent a backflow into the spinal cord vein. After embolization, the patient's symptoms improved. The mechanism of myelopathy in this case was considered to be vasogenic edema of the spinal cord due to venous hypertension. We stress the importance of making an early diagnosis of this pathology in order to administer the optimal treatment in a timely manner. In addition, the use of 3D-MRA in diagnosing such cases was found to be extremely valuable.

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