From January, 1978 to December, 1990, a total of 382 patients with a ruptured cerebral aneurysm have been treated by means of neck clipping, and from this number, the cases of 5 patients who experienced a delayed intracerebral hematoma (DICH) that occurred months or years after receiving the aneurysmal neck clipping have been studied retrospectively. In each of these 5 patients, who ranged in age from 25 to 61 years (mean : 46 years) , the DICH had, occurred without any new and/or residual aneurysm, and the interval between the clipping and the development of the DICH ranged from 8 months to 5 years (mean : 2 years and 5 months). In 3 patients, the hematoma had developed ipsilaterally to the side that had undergone the craniotomy, and in the remaining 2 patients, it was in a contra-lateral side. The location of the DICH was in the subcortex in 2 patients, in the putamen in 2 other patients, and in the thalamus of the remaining patient. Of note, 2 of the patients subsequently showed a recurrence of the DICH : after a clinical stable interval of 1 year and I month, I patient (Case 2) suffered a right temporal subcortical hemorrhage, followed by a right putaminal hemorrhage, and after an interval of 3 months, the other patient (Case 4) suffered a right parietal subcortical hemorrhage that was followed by a right thalamic hemorrhage. As for the etiology of these cases, 2 patients had a history of hypertension for which they had received antihypertensive drugs, 3 had severe spasms and stenosis of the parent artery on postoperative angiography, and 1 (Case 5) had undergone surgery for coarctation of the aorta at the age of 14. In addition to the findings of their retrospective study, the pathogenesis of DICH is discussed.

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A stereotactic biopsy of a lesion in the posterior fossa or in the occipital lobe is usually performed under general anesthesia, with the patient placed in a prone or a lateral position. Using another approach, the authors describe a biopsy procedure performed in a sitting position, which allows for the use of a local anesthesia. The advantages of this sitting position is not only that it minimizes the risk associated with the use of a general anesthesia, but also that it allows surgeons to monitor the patient's neurological function intraoperatively, so as to defect signs of any intracranial complication. This operative procedure is described and the cases of three typical patients are presented.

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The authors have previously reported on an operative mode, termed an 'extensive transbasal approach', for lesions in the frontal base, through which an osteotomized supraorbital bar is resected after a bilateral frontal craniotomy, and have widely applied this surgical technique not merely to benign tumors but also to malignant tumors of the frontal base. In radical surgery involving malignant tumors of the paranasal sinuses that have invaded the frontal base, it is important to perform an en-bloc resection of such tumors and surrounding healthy structures. The authors describe the case histories of 5 patients with a malignant tumor in the skull base. For their surgical treatment, a combination of the extensive transbasal approach and the transfacial approach was used, and the tumor and its surrounding structures, such as the dura and the orbital content, were resected en bloc. The operative results of these cases were relatively good. Since an en-bloc resection that resembles the authors' method has not been found in the Japanese literature, we discuss our technique, provide some representative cases, and comment on the relevant literature.

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Using gadolinium-DTPA-enhanced magnetic resonance imaging (MRI), 91 examinations of a brain infarction were conducted in 33 patients said patients ranging in age from 26 to 90 years old. Thirty of these examinations involved a cortical infarction and 61 a perforator area infarction, the onset of these infarctions ranging from O to 114 days. It was found that contrast enhancement of these lesions was most prominent at about two weeks after onset, and that the enhancement of cortical lesions lasted longer than that of perforator lesions. Further, differentiation between the infarction and its perifocal edema was difficult to determine in T2-weighted images, whereas Gadolinium-enhanced T1-weighted MRI clearly revealed the area of the infarction. Also, in cases of multiple infarctions, gadolinium-enhanced MRI was found useful in distinguishing recent lesions from older lesions.

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The authors report the case of a dural arteriovenous malformation (dAVM) in the anterior fossa that was associated with an aneurysm of the external carotid artery. The patient, a 53-year-old male, presented intracranial hemorrhaging of the right frontal lobe. Angiography revealed a dAVM in the right anterior fossa, fed by the bilateral ethomoidal artery, and a right sphenopalatine artery aneurysm of the external carotid artery. The etiology of a dAVM that is associated with an aneurysm of the external carotid artery is speculated to be developmental failure.

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The authors report the case of a 62-year-old man who was admitted to hospital in October 1987, because of transient left hemiparesis. On examination, a CT scan showed multiple small cerebral infarcts in the right cerebral hemisphere. Further, cerebral angiography revealed a dissection in the right cervical carotid artery, and measurement of his cerebral blood flow by IMP-SPECT showed a low perfusion into the right cerebral hemisphere. Repeated angiography demonstrated no restoration in the lesion one month later, so that a right STA-MCA anastomosis was performed two months after his admission. Postoperative cerebral angiography demonstrated the patency of this anastomosis between the right STA and MCA. Spontaneous dissecting aneurysms of cervical ICA are rare, and their therapeutic management has not yet been established. Most of the reported cases show a spontaneous restoration or recanalization of the lesions by conservative therapy. However, surgical treatment, such as a carotid endarterectomy or an EC-IC bypass, is indicated in cases where conservative therapy has had little or no effect.

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The authors report a case of a brain abscess that was caused by Aspergillus which occurred during the treatment of acute myelocytic leukemia. The patient was a 12-year-old boy who was admitted to the pediatric department because of repeated nasal hemorrhaging and fever. Bone marrow studies led to a diagnosis of acute myelocytic leukemia (M2 in FAB). During chemotherapy to treat the leukemia, however, headaches and general tonic convulsions developed. A plain CT scan revealed an area of low density that was surrounded by an area of high density in the left occipital lobe. At first operation, the abscess that was found was merely aspirated. Pathological examinations of the aspirated abscess material, however, demonstrated Aspergillus fumigatus. Therefore, after the patient's general condition had improved, the abscess was totally removed with its external capsule that had calcificated and was very hard. Postoperatively, the patient was treated with 5-FC and amphotericin-B and was achieved a good recovery. Infection of the central nervous system by Aspergillus usually appears in immunosuppressed patients, although its occurrence is quite rare. Our case revealed a very high density ring on plain CT scan, and the capsule was histologically confirmed to be a calciflcated granuloma. In such cases, aspiration cannot reduce the volume of the abscess, so that the abscess should be totally removed at the time of the initial operation.

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A case is reported of an internal spinal fixation using a Cotrel-Dubousset (C-D) instrument, which has never been reported by Japanese neurosurgeon, for a degenerative spondylolisthesis. A 74-year-old woman presented with low back pain, gait disturbance and tenderness on the lumbosacral paraspinal muscles. Physical examination disclosed no neurological abnormality except for a hypoactive patellar reflex bilaterally and a hyperactive ankle reflex more pronounced on the left side. Lumbar X-rays demonstrated slipping, which was more marked on flexion, of the L4 vertebra on the L5. A high resolution CT scan revealed a narrow spinal canal due to hypertrophy of the facets and the yellow ligament at the levevl of the L4 and L5. The theca was compressed more markedly on the left side. An MR-myelogram (T2-weighted : 2000/35) illustrated a complete block of the subarachnoid space and a compression of the theca at the L4/5 Ievel. A similar block of dye was likewise demonstrated in conventional myelogram. The degenerative lumbar spondylolisthesis was mild (less than 25%) which was classified into Meyerding's grade I. However, in consideration of patient's symptoms, ineffectiveness of 2-week conservative treatment and her eager desire for operation, surgery was finally indicated. C-D instrumentation of the L4 and L5 using pedicle screws, rods and a DTT (device for transverse traction) was performed following standard laminectomy of the L4 and medial facetectomy of the L5. Correction of the spondylolisthesis preserving physiological lumbar lordosis was successfully attained. This was confirmed by the postoperative radiology. The patient has been free from back pain and able to walk around in a normal posture since the 2nd postoperative day onward. Operative procedure and possible application of this technique are discussed.

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The authors report a rare case of a hemifacial spasm associated with ipsilateral trigeminal neuralgia caused by the vascular compression of two independent cerebellar arteries. The patient, a 33-year-old woman, had complained of twitching of the right facial muscles and an intermittent facial pain. On admission to hospital, the findings of her neurological examination were normal, except for intermittent facial twitching and pain. Thus, to remedy this, neurovascular decompression surgery was performed on these two lesions through a right suboccipital craniectomy. For the hemifacial spasm, an inferior paramastoid approach was ' used, and to alleviate the trigeminal neuralgia, the infratentorial lateral supracerebellar approach was used during the same craniectomy. After this neurovascular decompression was accomplished , the symptoms disappeared and no postoperative complications occurred. When two separate procedures are required for two different lesions through one craniectomy, a different anatomical approach for each respective lesion should be considered, since different operative approaches should be employed to prevent traction of the acoustic nerve.

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Reported is the case of glioblastoma multiforme detected in a 60-year-old, male, chronic hemodialysis patient who, on first coming to the authors' attention, had complained of headaches on waking up in the morning and disorientation. MR imaging reveald a huge right parietal tumor nearing herniation. Surgical decompression was deemed necessary but the patient's chronic need of hemodialysis presented surgical problems that had to be considered, namely the possibility of edema of the brain and his tendency to bleed. To control these problems, hemodialysis using nafamostat instead of heparin was performed slowly but frequently prior to surgery. Further, continual peritoneal dialysis was also provided during surgery. Also, intraoper-atively, glycerol instead of mannitol was administered intravenously and hyperventilation was provided. Based on these procedures, brain edema was well controlled nor were any problems encountered involving hemostasis. The tumor was resected subtotally and no complications occured during the postoperative period. In addition to describing this case, the perioperative management of chronic hemodialysis patients is discussed.

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Reports describing the endoscopic findings in patients with a syringomyelic cavity and a Chiari type 1 malformation are extremely rare, and the authors discuss the case of an aggravated sensory disturbance of the trunk and extremities in a 21-year-old female who, 5 months earlier, had undergone syringosubarachnoid shunt surgery for syringomyelia associated with a type 1Chiari malformation. On hospital admission, an MRI revealed that a syringomyelic cavity as large as her previous syringomyelic cavity had developed from the C2 Ievel to the lower thoracic level. Thus she underwent a second syringosubarach-noid shunt operation. A flexible fiber catheter with an outer diameter of 0.75 mm that was inserted into the shunt tube clearly showed the total obstruction of the lumen by granulomatous tissue. Prior to inserting a new shunt tube into the syrinx, this flexible fiber catheter made it possible to safely observe the entire syringomyelic cavity and its smooth wall. Within the cavity, trabecular tissue strands and blood vessels were detected crossing the cavity to the opposite wall. In addition to presenting the details of this case, the authors also discuss the clinical use of endoscopy for evaluating a syringomyelic cavity.

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Many cases of an intracranial aneurysm associated with a polycystic kidney disease (PKD) are found in the literature, but only 30 domestic cases have been reported. Herein, the authors report a recent case of an intra-cranial aneurysm that was complicated by PKD. A neck clipping of the aneurysm was performed but a postoperative CT scan showed intracerebral hemorrhage. They thus investigated the patient's family for signs of PKD. Her daughter was diagnosed as having a PKD, but no intracranial aneurysms were found on MR angiography. The authors emphasize the importance of detecting possible intracranial aneurysms in PKD patients, since the rupture of an aneurysm could prove critical. In the management of cerebrovascular disorders, including intracerebral hemorrhage, it is necessary to detect any associated PKD, especially at the time of operation. Also, extreme care must be taken since the blood vessels of PKD patients are very fragile.

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The authors discuss a spatula that has been devised with a new type of tip which, when used in cranial surgery, prevents the cranial nerves and blood vessels from being injured. This spatula also is beneficial in preventing cerebral lacerations and/or tearing when used in widening a corticotomy. The main innovation that distinguishes this spatula from other spatulas is that one tip has a semicylindrical shape whereas the other tip has been left flat, and since this spatula is made of copper and has a teflon coating, it can be bent to form a desired shape. Also, When used for a tumor removal or the evacuation of a hematoma, the spatula can be attached to a self-retaining retractor. This new spatula in now commercially available, and has been used in over ten cases that have included an intracerebral hematoma, a cerebellar tumor, a cerebello-pontine angle tumor, and the dissection of a sylvian fissure for an aneurysmal clipping, and in no instance did a complication develop.

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For high risk patients, before a therapeutic occlusion of the internal carotid artery or an endoarterectomy, the balloon Matas test is often a necessary procedure. The balloon Matas test is particularly useful, since it allows measurement of the stump pressure during the temporary occlusion of the internal carotid artery. However, when ostial stenosis is involved, the direct insertion of a rigid pressure-measuring balloon catheter Into the internal carotid artery presents a significant risk. Therefore, so as to avoid any risk, the authors have employed the balloon Matas test using a double balloon catheter, and by simultaneously occluding both the external and common carotid arteries, they were thus able to measure the pressure at the carotid bifurcation. Thus, if the bifurcation pressure can be regarded as being equivalent to the stump pressure of the internal carotid artery, this double balloon catheter method can offer a safer way to measure stump Pressure when treating cases of ostial stenosis. They report their results and describe the design of this useful catheter.

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