The platelet-derived growth factor (PDGF) content in the cerebrospinal fluid (CSF) has been measured in 13 consecutive patients with an aneurysmal subarachnoid hemorrhage (SAH). The CSF samples were obtained through a cisternal or a ventricular catheter. From 2 to 6 samplings from each patient were evaluated within 13 days after, t he time course of the PDGF content was studied as well. A radioimmunoassay (double antibody technique) was used for PDGF measurement, and each patient's preoperative grade (Hunt > Kosnik) and CT group on onset (Fisher), as well as the presence of a vasospasm, and the outcome at discharge were compared with the data of the PDGF content in the CSF. Ten SAH patients (77%) showed an elevated PDGF concentration in their CSF within 4 days after SAH onset (160 ∿ 3700 pg/ml), whereas neither patients in the subacute SAH stage nor patients (controls) with another type of intracranial lesion showed any such elevation of the PDGF content in their CSF that could be detected. Further, no significant correlations were established between the PDGF content and the clinical grade, CT group, the presence of vasospasms, or the outcome. Based on these results, it would appear that PDGF is released into the CSF during the early SAH stage, and that this PDGF release may be capable of exerting an effect from the abluminal surface of the cerebral artery. While the exact mechanisms of how this proliferative angiopathy develops has not been substantiated, it thus would seem that during the acute SAH stage some preventive treatment should be initiated to inhibit this proliferative process within the vessel wall.

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Nine patients with an epidermoid of the posterior fossa that was surgically treated during the past 15 years have been reviewed, especially in relation to trigeminal neuralgia and/or facial spasm. These cases consisted of 4 male and 5 female patients with an age range of 34 to 68 years (mean : 50 years), and the epidermoid site was the cerebellopontine (CP) angle in 7 cases and the fourth ventricle in 2 cases. The presenting symptoms varied, and the duration prior to operation ranged from 2 months to 11 years. A total or a subtotal resection of the tumor in all cases was able to yield an Improvement in the symptoms and a useful life of 2 to 15 years, based on a long-term follow up survey. Of the 7 cases with a CP angle lesion, there was I case that manifested a painful tic convulsif, I case showing trigeminal neuralgia, and 1 case with a facial spasm. In the operative findings of these cases, the trigeminal inlet zone at the pons was found to be completely surrounded by the tumor, while the facial nerve was compressed by not only the tumor but also by the artery. Thus, microvascular decompression of the facial inlet zone was performed after tumor resection. Total tumor removal and microvascular decompression resulted in complete relief from the trigeminal neuralgia and/or facial spasm. These results are discussed with a review of the literature.

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Twelve cases of a bilateral symmetrical aneurysms (BSAs) of the middle cerebral artery (MCA) have been analyzed with special reference to the use of computerized tomography (CT) and angiography for assessment and the surgery used. Among the total patients with MCA aneurysms the authors' facility has handled, the incidence of BSAS amounted to 8.1%. Clinical signs that were indicative of the site of the ruptures were present in only 25.0% of the cases, and CT revealed the lateralized findings in 75.0% of the cases. CT and cerebral angiography made it possible to identify the ruptured side in 91.7% of the cases. Based on the laterality revealed by CT and angiograms, the cases were classified into three groups : Group 1, an asymmetrical hemorrhage revealed by CT (9 cases) ; Group 2, a symmetrical hemorrhage revealed by CT and a significant laterality seen in angiograms (2 cases) ; and, Group 3, no laterality seen either by CT or angiograms (on cases) . A two-stage operation was used for Groups I and 2 : the first, to treat the ruptured aneurysm, and the second, to treat an unruptured aneurysm. Cases showing no laterality should be treated by a bilateral one-stage operation. Discrepant CT and angiographic laterality findings may indicate an intra-aneurysmal thrombus formation.

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To see whether it is possible to predict the outcome of a cerebral ischemic attack in patients with a previous subarachnoid hemorrhage (SAH), the intracranial hemodynamics have been evaluated In 43 SAH patients. Using transcranial Doppler blood flow mapping (TCDM), the flow velocity (FV) and Fourier's transformed pulsatility index (FPI) of 10 harmonics (FPI_<1-10>) of each patient were analyzed, and based on the type of vasospasm, the patients were divided into five groups, i. e., groups I, II, IIIa, IIIb, and IV. In all five groups, a significant correlation was found between the appearance of delayed neurological deficits (DINDs), the I ^<123>-IMP-SPECT, and conventional CT findings, and the Glasgow Outcome Scale (GOS). Group I had the best outcome, whereas group IV had the poorest prospects. Possible hyperemia and/or an increased blood volume was suspected in patients in group II who showed an FV greater than 120 cm/s and a decreased FPI_1 (&le; 0.15) , but no DINDS Were noted nor were ischemic lesions seen on CT, and the final outcome was good. In groups IIIa and IIIb, many cases showed an Increased FV (&ge; 120 cm/s) and an FPI_1 that was either normal (0.15 <FPI_1 &le;0.30 : IIIa) or increased FPI_1(0.30 <FPI_1 &le;0.50 : IIIb) , as well as increased FPI_<5-6> values, DINDs, and ischemic lesions on SPECT and CT visualization. Our results have indicated that the prognosis for SAH patients with a vasospasm is poor, if there is an increase in both the FV and FPI_<1,5,6> Values, since DINDS and irreversible cerebral ischemia are likely to occur.

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Malignant tumors originating in the paranasal sinuses and nasal cavity frequently involve the anterior or middle skull bases. Since 1984, we have experienced a total of 17 patients underwent radical surgery by supraorbital transbasal or orbitozygomatic approaches. Histology of the tumors includes 9 of squamous cell carcinoma, 2 of olfactory neuroblastoma, 6 of undiffentiated carcinoma, Iymphoepithelioma, mucoepidermoid carcinoma, mesenchymal chondrosarcoma, plemorphic adenoma and papilloma. They were 11 with anterior base invasion and 6 with middle base invasion. The age ranged from 24 to 76 years. Postoperative follow-up ranged from 100-l months with average of 25.3 months. : mean period of 33.2 months for patients with anterior skull base surgery and 13.6 months for middle skull base surgery. Thirteen patients are alive with disease free (over 3 years : 2, less than 3 years : 11) whereas one is alive with metastasis. Among them, one patient with undifferentiated carcinoma died after anterior skull base surgery and all others is free of disease. But 2 out of patients underwent middle skull base surgery died of the disease and one is alive with metastasis. A11 these patients had extensive tumor invasion in the cavernous sinus. Other 3 patients with or without partial invasion in the cavernous sinus are free of disease. There was no intra- or perioperative mortalities. Although further follow-up is needed, radical resection of tumor by our surgical procedures will give the patient with skul1 base invasion a better chance for a cure.

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The lumbar CSF pulse waves, pressure buffering capacity, and the CSF flow resistance of 19 patients with blockage of the spinal subarachnoid space were monitored before and during surgical cord decompression. In all patients, a significant increase in the pulse amplitude, pressure buffering capacity and significant decrease of CSF flow resistance soon after decompression was accomplished. Further, neither anterior nor posterior decompression yielded any statistically different values in these parameters. The authors thus have concluded that successful removal of a subarachnoidal block may improve the pulse pressure transmission within the cranio-spinal cavity, and that this easy method is able to provide a reasonably accurate intraoperative assessment of spinal subarachnoid block release.

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The authors have analyzed the overall surgical results of 40 ruptured vertebral artery (VA) aneurysm cases and discuss aspects of treatment. Depending on the type of aneurysm, these cases were classified into two groups : 1) a saccular aneurysm, and 2) a dissecting aneurysm. Twenty-seven cases consisted of saccular aneurysms [Hunt and Kosnik (H and K) Grade I: 10 cases. I a : 5, II: 2, III: 7, IV: 3], 25 of these cases being an aneurysm at the junction of VA and PICA, 1 an aneurysm at the distal portion of the PICA, and 1 an aneurysm at the VA trunk. Aneurysmal clipping was the surgical procedure for all cases, and in 7 cases the surgery was performed within 3 days after an SAH. The six month follow-up outcome was found to be excellent in 19 cases, good in 1 case, fair in 1 case, poor in 4 cases and 2 cases ended in death. The causes for unfavorable outcomes in 7 cases were primary brain damage in 2 cases, a vasospasm in 2 cases, and other medical complications in 3 cases. Thirteen cases consisted of dissecting aneurysms (H and K Grade I : 7, I a : 3, II: 2, III : 1). In 2 case surgery was performed within 3 days after an SAH. A total of 15 operations were performed for 13 cases (coating : 10, VA trapping : 2, clipping at the bleeding point : 2, VA proximal clipping : 1), and the outcome has been excellent in 9 cases, good in 2 cases, poor in I case and I case ended in death. The causes for unfavorable outcomes in 2 cases were a surgical procedure and a rebleeding. Based on these results, it can be concluded that early clipping is indicated for cases of a ruptured VA-PICA aneurysm, so as to prevent a delayed vasospasm and medical complications, and that VA trapping or careful coating can result in a favorable surgicai outcome for cases of a ruptured VA dissecting aneurysm.

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The authors report the case of a pituitary adenoma associated with a Rathke's cleft cyst in a 58-year-old man suffering from a visual disturbance. Tests on hospital admission revealed that his visual acuity was 0.2 on both sides and bitemporal hemianopsia. Further, an endocrinological study disclosed panhypopituitarism. Also, CT scans revealed ring-like enhancement of a low density mass that extended into an enlarged sellar cavity and into the suprasellar region, and MRI also showed a cystic mass in the sellar cavity that extended into the suprasellar region. Thus, a right frontal craniotomy was performed. Brownish colloidal fluid was first aspirated, after which the capsule of the cyst was excised. The postoperative course was uneventful, and the patient's visual acuity and visual field defects improved. Histologically, the tumor was a pituitary adenoma and its cells were mainly found to be composed of chromophobic cells. The wall of the cyst in the pituitary adenoma was composed of ciliated and non-ciliated columnar epithelium intermingled with goblet cells, indicating a Rathke's cleft cyst. Therefore, based on these findings, it appears that a combined pituitary adenoma and a Rathke's cleft cyst can occasionally coexist, so it should not be assumed that a cyst is a transitional cell tumor.

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The authors discuss the case of an 11-year-old female admitted to our institute because of repeating transient ischemic attacks caused by hyperventilation. Cerebral angiography disclosed multiple occlusions of the bilateral internal carotid arteries and the left vertebral artery, and stenosis of the right vertebral artery. Moreover, distal portions of the occluded internal carotid arteries by basal moyamoya-like vessels was also visualized. However, cerebral angiograms showed the bilateral C_1 segments, the P_1 segments, the posterior communicating arteries, and the anterior communicating artery were still intact, and the circle of Willis, except for the A_1 region, was clearly recognized. Further, encephaloelectrograms revealed the typical re-build up phenomenon. This case presented a moyamoya disease-like pattern after hyperventilation, provoking the same hemodynamic mechanisms that cause ischemic attacks in patients with moyamoya disease.

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The authors describe the case of a 54-year-old female with over a 10-year history of hyperthyroidism. Magnetic resonance images revealed a pituitary microadenoma and after transsphenoidal removal of this tumor, her signs and symptoms of hyperthyroidism almost completely disappeared. Pituitary tumors associated with TSH hypersecretion are rare, with only slightly over 100 cases having been thus far been reported. The authors have reviewed 103 of these TSH-secreting pituitary adenoma cases, and found that most of these tumors are macroadenomas and more than 1 cm in size. Thus, the case herein described is the first report of a TSH-secreting pituitary microadenoma that was detected by MRI.

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The authors report the case of a 15-year-old boy with Glanzmann's thrombasthenia and a chronic subdural hematoma. At 3 years of age, based on hematological studies at their hospital, this patient was diagnosed as having thrombasthenia. On May 13, 1991, he was admitted to hospital because of a headache and nausea. A CT scan of the head revealed a left subdural hematoma. Further, his bleeding time was markedly prolonged. Therefore, after a transfusion of fresh blood and platelets, a craniotomy was performed, and his post-operative course has been excellent. Glanzmann's thrombathenia is a rare congenital platelet disorder characterized by a prolonged bleeding time, a qualitative platelet defect, and severe hemorrhagic episodes. However, cases of an intracranial hematoma associated with Glanzmann's thrombasthenia are rare. The authors wish to stress the importance of a CT scan of the head for thrombasthenia patients with a tendency to bleed, because a chronic subdural hematoma does not always show specific symptoms, and the hematoma can be treated in such patients by a simple burrhole operation.

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Several reported laminoplasties made no mention of yellow ligament biomechanical reconstruction as one of the important posterior Sustaining elements in cervical surgery. Transverse laminotomy, coined by the present authors, is successfully done by microneurosurgical technique traversing the mid-half of the lamina and spinous process by 1.5 mm ball bar drilling. This procedure causes no injury to the yellow ligament, since it adheres tightly to the lower half and the next upper third of the back of the laminae. When the traversed lamina and spinous process are re-fused in a simple manner and other laminae are reconstructed by Koyama's method of laminoplasty, the biomechanism of yellow ligament can be spared in the longitudinal direction. This is the first paper indicating the method of sparing the biomechanism of yellow ligament even after laminotomy. And neurosurgeons, who have well mastered microsurgical techniques, can prepare the necessary minimum operative fields for intra-spinal canal procedures.

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