Risk management is supposed to be the first priority issue in many clinical fields including neurosurgery at present. The quality control of medical practice is particularly indispensable in high risk field such as neurosurgery. However, as it is apprehensive that the open and straightforward discussion on the concrete events and all incidences may invoke unnecessary controversies, the practical concrete risk management in each field is not always well investigated. The most controversial point is the definition of incidence, malpractice and complications. These three categories are discriminated by complicated factors such as its severity, frequency and artificial error. It is quite important to have an open discussion on the every event from this point of view by all members in its facilities. In clinical neurosurgery, most of incidences occur in the ward. Among them, drainage trouble and fall down trouble are most frequently seen in neurosurgical ward. However, the most serious incidences occur in operating room. Residual foreign body such as cotton paddy is most frequently encountered. The thoroughgoing practice of manual to prevent this incidence is quite effective. In examination room, angiography has high risk. Some complications such as cholestelin embolus are still inevitable. The most practical risk management is to avoid unnecessary procedures. In out-patient clinic, the misdiagnosis such as the minor ischemic event is critical. This incidence is often caused by the system of its facility. As conclusion, for the more effective and practical risk management, we neurosurgeons have to organize the systematic nationwide data accumulation.

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Despite recent advances in surgical techniques, chemotherapy and radiotherapy, the poor prognoses of malignant glioma patients have not changed in the past decades. The use of oncolytic viruses is a promising new strategy for treating cancer including malignant glioma. The basic concept of oncolytic virus therapy is to kill the tumor cells via infection with replication-competent viruses such as herpes simplex virus. This concept, however, was not practical until the recent progress in genetic engineering enabled a manipulation of the viral genome to restrict the virus replication to tumor cells. Oncolytic viruses can also serve as vectors that can provide an amplified transgene delivery within the tumor. Multiple oncolytic virus vectors have been tested in clinical trials for malignant gliomas, most by direct intratumoral administration, the results of which have demonstrated the feasibility and potential of this therapeutic approach. The efficacy of oncolytic virus therapy may be enhanced by combining it with other adjuvant therapies. There remain problems to be solved which include how to obtain maximum delivery of the virus to tumor cells via systemic administration without losing a substantial amount by attachment to the vessel wall, hemodilution, filtration in the liver, and inability to pass the blood-brain barrier. Nonetheless, the development of oncolytic virus therapy may lead to a breakthrough in the treatment for malignant gliomas.

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In this paper, we describe the general concept, classification and treatment of craniosynostosis. Craniosynostosis is a disorder in which there is early fusion of the sutures of the skull. It produces an abnormal shape of the head and face. The deformity varies significantly depending on the affected sutures. Surgical correction may be necessary to improve appearance and provide space for the growing brain. Multi-disciplinary team cooperation is mandatory to treat these cases. We emphasize that early treatment leads to better results.

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We discussed the treatment guidelines for fetal hydrocephalus, which has many unresolved clinical and ethical problems. Before delivery, we should make an accurate diagnosis of the basic disease, decide on the time and method of delivery and give information, counseling and support to the parents. As there is no evidence that early treatment of fetal hydrocephalus brings a good outcome, it is usually recommended to have delivery after 37 weeks of gestation and the way of delivery is to be decided by obstetrical indication. The first choice treatment is a ventricular-peritoneal shunt (V-P shunt). V-P shunts should be performed on patients whose body weight (BW) is over 2,000-2,500g. For those under 2,000g BW, placement of reservoir and intermittent drainage are usually carried out until BW exceeds 2,000-2,500g. For patients with myelomeningocele, V-P shunts are usually performed several days after the repair. In cases where meningitis is accompanied or the repair is delayed, transit ventricular drainage is recommended before carrying out the V-P shunt. The conditions in foreign countries and the present situation of intrauterine surgery are also discussed.

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Computed tomography (CT) and magnetic resonance (MR) imaging have significantly improved the diagnosis of brain tumors. However, brain tumor is still sometimes difficult to distinguish from stroke in patients presenting with acute neurological symptoms. Four hundred and two patients with glioma received initial treatment at our hospital from June 1995 through May 2005. Among these patients, 8(2.0%) were initially treated under a misdiagnosis of stroke. Brain CT and MR imaging at onset, and angiographical examinations in some of these 8 patients, failed to detect the tumor. The misdiagnosis was intracerebral hemorrhage in 3 patients, subarachnoid hemorrhage in 1, and cerebral infarction in 4. Early and accurate diagnosis can lead to better outcome in patients with glioma. Meticulous follow up of similar patients using MR imaging may improve the diagnostic accuracy and therapeutic outcome.

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We report a rare case of olfactory groove schwannoma. A 28-year-old male was admitted complaining of worsening chronic headache. Neurological examination revealed anosmia on the left side. Neuroradiological examination including MRI demonstrated an intradural extraaxial tumor measuring 5cm in diameter in the left frontal base. Operatively, total resection was performed. The tumor had an attachment at the olfactory groove. Histological examination was compatible with schwannoma, Antoni B type. There were several postulations about its origin, mainly that the schwannoma originatd from either the olfactory nerve or a nerve intimated with it.

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Rhinocerebral mucormycosis refers to uncommon opportunistic fungal infections reported to occur especially in association with diabetic acidosis, immunosuppressive therapy, malignancy, or other chronic debilitating disorders. However, patients with no underlying disease have occasionally been affected. The patient was a 59-year-old man with initial complaints of retrobulbar pain in the right eye, and forehead pain. He had no apparent immunocompromising illness. Magnetic resonance imaging revealed a mass invading the right orbital apex with extension into the right middle fossa. The mass was partially removed. The pathological diagnosis was mucormycosis. Two weeks after the operation he developed left hemiplegia. Right carotid angiogram showed occlusion of the middle cerebral artery. We started intravenous amphotericin-B therapy. There has been no disease progression. Based on our experience we emphasize that rhinocerebral mucormycosis be considered as a differential diagnosis in healthy individuals as systemically ill individuals presenting with orbital infections.

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In the patients with symptomatic occlusion of the internal carotid artery (ICA), maximal treatment seldom results in a favorable outcome. We performed recanalization therapy using mild hypothermia with left ICA occlusion, and obtained good results. A 59-year-old man, his NIH stroke scale was 27 points. Angiography revealed left cervical ICA and left middle cerebral artery (MCA) occlusion. The ICA occlusion was treated by carotid angioplasty and stenting (3 hours after onset), and the MCA occlusion was treated by local intraarterial fibrinolytic therapy (4 hours after onset). In patients with the symptomatic ICA occlusion, because hypothermia needs to be initiated as soon as possible, induction of hypothermia therapy should take precedence over the recanalization therapy. ICA occlusion needs to be classified based on the difficulty of the racanalization therapy.

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