The reported annual incidence of acromegaly is 3-4 cases/one-million people and prevalence is 38-69/one-million. The incidence in Japan is estimated around 500 cases/year. Despite the fact that almost all of cases of the acromegaly were caused by GH producing pituitary adenoma, some rare pathologies such as ectopic GH secreting tumors and GH-RH producing tumors may also be causative factors of this disease. In general, picking up on the characteristic features of acromegaly leads to the correct diagnostic process. Recently, symptoms other than the features, such as impaired glucose tolerance, carpal tunnel syndrome, malocclusion of jaws, or sleep apnea syndrome occasionally becomes clue to the diagnosis. For the definitive diagnosis, verification of excessive growth hormone secretion, high blood IGF-1 level, and the existence of pituitary adenoma on magnetic resonance imaging is essential. Because of its pulsatile nature of secretion, the blood GH level in the healthy population briskly changes. Therefore, the random measurement of GH level sometimes fails to differentiate the normal physiological diurnal rhythm of GH secretion from GH hypersecretion. The definition of GH hypersecretion should be based on a nadir GH level being under 1 ng/mL during a 75 g glucose tolerance test. It is important to know that blood GH level may increase in some physiological or pathologic conditions, such as pain, puberty, stress, prolonged fasting, chronic renal failure, heart failure, diabetes mellitus, and malnutrition. IGF-1 is produced in the liver under the control of GH. Its blood concentration minimally fluctuates and represents total GH secretion for the previous several days. Blood IGF-1 levels in the normal population, however, vary according to gender and age. Therefore, the validation of the IGF-1 level should be based on the standard range of IGF-1 of a gender and age-matched control.

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Acromegaly, a condition due to growth hormone hypersecretion usually from a benign pituitary tumor, is associated with significant morbidity and mortality. Therapeutic goals are normalization of life expectancy with a reduction in signs and symptoms. Surgery is the primary therapy. But most patients also have macroadenomas, and require additional medical therapy. This review will focus on emerging concepts in the medical therapy of acromegaly.

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To establish the best combination modality for the treatment of Acromegaly, 174 cases of personally operated patients with Acromegaly were analyzed. The results of transsphenoidal surgery were analyzed in 20 cases operated on during the last one year. And the results of adjuvant gamma knife treatment after transsphenoidal surgery were analyzed for the 20 cases which were followed-up more than 18 months. The operative cure rate was 75 %. Even if total removal of the adenoma was not achieved, successful dose planning of adjuvant gamma knife treatment will accomplish a cure, in a high rate (100%), under the condition that the pre-gamma GH value was reduced to less than 10μg/l. On the other hand, there were no cases that achieved a cure in which the pre-gamma knife GH value was more than 10μg/l. The concept of effective treatment for acromegaly has been changing from one of "Transsphenoidal surgeryis the first choice of treatment" to "To remove tumor extensively as much as possible by transsphenoidal surgery is the first step for the treatment of acromegaly".

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In our hospital, if a patient fall into a brain dead state or close to a brain dead state, the option of deceased donor kidney transplantation is proposed or recommended. As a result, ten donors were obtained in the recent four years. Those ten cases were ・ four traumas, four SAHs, one intracerebral hematoma, and one cerebral embolism. Among the twenty kidneys from the ten patients, seventeen kidneys were transplanted into recipients, and sixteen kidneys functioned satisfactorily eventually. Among the three unused kidneys from two patients, one kidney suffered from direct traumatic damage, and two kidneys from one patient were colored blue due to intra-arterial thrombosis. In the patient with the blue kidneys, a persistent hypoxic state, no irrigation of the preservation fluid, failure of the heparinization, and elongation of the warm ischemic time were considered to have affected the thrombosis. On the other hand, the kidneys successfully transplanted showed good tolerance and viability under such severe conditions as oligouria, anuria, acute renal failure, and hyperthermia. The neurosurgeon must play an important role as an organizer in organ transplantation. For the purpose of the promotion of deceased donor kidney transplantation in Japan, the enlightenment of the neurosurgeons is essential.

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We evaluated the treatment results of bilateral endonasal endoscopic transsphenoidal surgery. The surgical procedure was as follows. The otolaryngologist worked, using the bilateral endonasal approach and the anterior wall of the sphenoid sinus was widely opened. The endoscope was held at the right nostril. After that, the sella surgery was performed by the neurosurgeons. The radicality of tumor removal was improved by the wide view and no patients suffered postoperative complications. By using both nostrils, we can obtain both smoothness and convenience during endoscopic transsphenoidal surgery. We emphasize the importance of collaboration between the neurosurgeon and the otolaryngologist while performing these procedures safely for surgeons moving from microscopic surgery to endoscopic surgery.

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The phase III study about the effectiveness of cortical stimulation in the treatment of stroke patients with upper extremity hemiparesis is currently in progress in the U.S.A., and the preliminary evidence is encouraging. We describe a 59-year-old woman who had a subcortical infarct and right hemiparesis 20 months after a stroke who received daily epidural motor cortex electrical stimulation during occupational therapy for 4 weeks. The patient underwent a small craniotomy for placement of an epidural cortical electrode on the hand motor cortex, which was identified with a computerized navigation system according to the findings of functional magnetic resonance imaging, somatosensory evoked potential, and motor evoked potential. Before treatment, she was unable to extend her fingers. After four weeks of treatment, the movement of her hand had improved, and the Fugl-Meyer motor scale score had increased from 27 to 46. The improvement was sustained. The motor cortex stimulation concurrent with occupational therapy may enhance motor recovery from stroke.

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