As a young neurosurgeon in training (post graduate 15 years), personal experiences to develop neurosurgical skills during this period are presented, especially from the aspect of how to learn neurosurgery from one's mentor. Nowadays, young neurosurgeons need to hone their skills using a lower surgical case volume compared to what their mentors have experienced due to today's less invasive alternative treatments and social demand for "safety". To overcome the difficulties imposed by this reduction, the author and colleagues underwent thorough suturing training using 10-0 nylon under a desk type microscope, accumulating 20,000-100,000 stitches over the past 2-10 years. This simulation training enabled us to experience and to perform real neurosurgical microoperations by ourselves under supervision of a senior mentor without compromising "safety". Another important aspect to improve surgical skills during the in training period is to acquire mental toughness, in other words "professionalism", to cope with the stressful situations encountered during difficult neurosurgical procedures. An extremely busy daily schedule during neurosurgical residency, if well tolerated, should further contribute to build up such mentality.

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The training system established for neurosurgical residents seems to have functioned very well so far in the University of Tokyo group. The trainees are required learn how to adopt new techniques and/or concepts in addition to developing their own surgical skills. Looking back on its history, surgery has continuously divided into new subspecialties. Board certified neurosurgeons are required to follow any advances in the field and to keep abreast of the latest technologies. They are increasingly recommended to establish their own subspecialty because the level of basic research as well as clinical neurosurgery has become increasingly higher and higher. We also need to consider the purpose of our research activities. Due to an evolving health care enviroment and the challenges posed by an aging society, the lifelong continuous education system will become increasingly important for neurosurgeons.

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Our training system for neurosurgeons specializing in cerebrovascular surgery is introduced in the paper. Our institute provides training programs for young neurosurgeons on cerebral aneurysm surgery and entracranial-intracranial (EC-IC) bypass surgery. In the program for aneurysm surgery, preoperative and postoperative discussion is very essential, because aspects of surgery are just knowledge at first and then become skills. In the program for EC-IC bypass, trainees are introduced to our technical training program on a step-by-step basis. These programs, being provided as packages, can introduce young neurosurgeons to a master-and-apprentice relationship. With mastering the programs, trainees can obtain surgical skills as well as enough knowledge and theory, which are necessary for the vascular neurosurgeon. I think the goal of the program may be to enrich the life of each trainee as a neurosurgeon including their private life.

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The postgraduate education system for neurosurgeons in the Department of Neurosurgery, at Keio University Hospital is described. The importance of and some issues to be solved in the near future with the hands-on seminar and the cadaver dissection course are discussed. My policy for brain tumor surgery and how to train future brain tumor surgeons is also described.

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The importance of spinal surgery in the practice of neurological surgery in Japan is increasing every year, although spinal surgery is not yet a major subspecialty in Japan. Therefore, spinal surgery training for young neurosurgeons is an important issue. How to best educate neurosurgeons with little experience in spinal surgery is discussed in this paper.

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A case of huge intraosseous and subcutaneous meningioma presenting transformation of head like a rugby ball is described. He was admitted to our hospital with an elastic hard, painless growing mass in parietal and occipital region. Neurological examination and laboratory data was revealed no abnormalities. Bone target CT showed a wide range of osteoblastic lesion in parieto-occipital skull. Gd-enhanced magnetic resonance images (MRI) showed large homogeneous enhanced tumor at subcutaneous and intradiploic portions, and small enhanced tumor at subdural parasagital portion. At biopsy, subcutaneous and intradiploic tumor proved benign meningothelial meningioma. After biopsy, subcutaneous, intradiploic and parasagittal meningiomas were resected as far as possible with no complications and cranioplasty was performed with a titanium sheet. Microscopically there was not a relation between extradural tumor and intradural parasagittal tumor. Follow-up MR images was present no tumor regrowth one and a half year after surgery. Intraosseous meningioma was extremely rare. Especially unusual appearance was presented by this rare case, so we present clinical course of this case and reviewed clinical charactaristics on medical literatures.

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A 54-year-old male presented with orthopnea. His illness was diagnosed as dilated cardiomyopathy (DCM) on an ultrasonic cardiograph (UCG). He was sent to our hospital, and admitted to the cardiovascular systems department. He had acromegalic features and a complete medical examination was performed. He was found to have a high level of growth hormone (GH) and a pituitary adenoma on MRI of the brain. His cardiac function abnormality was caused by a GH producing pituitary adenoma. He underwent transsphenoidal surgery. The level of GH and insulin-like growth factor-1 (IGF-1) fell after tumor removal. His symptoms immediately improved and his cardiac function gradually improved. His cardiothoracic ratio (CTR) and ejection fraction (EF) normalized after 5 months post-operation. Tumor removal resulted improved cardiac function with the normalization of GH level.

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A 50-year-old female complained of swelling and dysesthesia on the right side of her face. Neurological examination showed no deficits. An MRI showed a tumor located in the infratemporal fossa which had extended into the right middle cranial fossa and into the right temporal muscle, partially invading the cavernous sinus. A biopsy diagnosed the tumor as meningioma. After preoperative feeder embolization of the tumor, the tumor was removed. The space resulting from the tumor removal was reconstructed with an inferior lateral rectus abdominis musculocutaneous flap. After the operation, her consciousness gradually decreased. Diagnostic imagings revealed that the musculocutaneous flap was compressing the brain, and we thought that was the cause of her decrease in conscious level. Four days after the operation, we debrided a part of the flap, and then her conscious level improved. We report a rare case of a decrease in conscious level due to a swelling musculocutaneous flap that was compressing the brain, and consider the causes.

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A 61-year-old female inpatient suddenly experienced right hemiparesis and aphasia. She had known mitral valve stenosis and massive thrombus in the left cardiac atrium. Diffusion weighted MRI disclosed an extensive acute ischemic lesion in the left middle cerebral artery (MCA) territory. Catheter angiography showed occlusion of the left MCA. A Merci Retrieval System removed a few hard organized clots and complete recanalization was obtained about two hours after presentation. Her neurologic deficits resolved rapidly, and most of the ischemic lesion on diffusion weighted MRI disappeared. Cardiac surgery was done, and a large organized clot was removed from the left atrium. For cardiogenic organized clots, fibrinolysis is ineffective. Early recanalization using mechanical clot removal resulted in excellent clinical and radiological outcome in this case.

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