Eleven cases of a nonaneurysmal perimesencephalic subarachnoid hemorrhage (NP-SAH) have been analyzed with special reference to the findings of computerized tomography (CT), magnetic resonance imaging (MRI), and cerebral angiography to know the bleeding site. Among the total number of patients with a nontraumatic subarachnoid hemorrhage (SAH) that the authors' facility has handled, 597 patients underwent cerebral angiography, and the number of SAH cases with an unknown etiology amounted to 27 (4.5%). In 11 of 20 patients with negative SAH angiographic results but with an apparent SAH on CT, the main SAH site was the perimesencephalic cisterns. The dominant SAH site on initial CT was the interpeduncular cistern, and the SAH site on CT from 8 to 21 days after SAH was also the interpeduncular cistern. The SAH sites on MRI from 7 to 11 days after SAH were the interpeduncular cistern and prepontine cistern. Repeated angiograms from 7 to 12 days after SAH showed vasospasms mainly in upper trunk of the basilar artery. These findings suggest that the bleeding site in NP-SAH may be the basilar artery or its branches in the interpeduncular and prepontine cisterns. However, this study was unable to clarify the pathological cause of NP-SAH.

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A traumatic intraventricular hemorrhage (IVH) is a neuroradiological finding indicative of a diffuse brain injury and carries a poor prognosis. This study clarifies the clinical implication of a traumatic IVH, especially in patients with a simple traumatic IVH with no other complications. In this study, a diagnosis of traumatic IVH was based on the findings of computerized tomography (CT) performed within 6 hours following the head injury. Excluded from this study were patients whose initial but not follow-up CTS showed an IVH, so as to eliminate a ventricular reflux as an etiology of the intraventricular blood. Also excluded from this study was a patient with an IVH that was due to an intraventricular rupture of an intraparenchymal hematoma. Thus, a total of 5 patients with a simple traumatic IVH were studied. On admission to hospital it was found that the Glasgow Coma Scale score had varied, but although all 5 patients were unconsciousness, 4 patients recovered within 48 hours of their injury. In contrast, the outcome was less favorable for 5 other patients who had a traumatic IVH associated with a primary brainstem injury and/or diffuse brain swelling, and all these latter patients ultimately died or lapsed into a persistent vegetative state. Further, of 7 patients with a traumatic IVH and a focal brain injury, 6 (86%) had a favorable outcome. It thus has been concluded that the outcome of a traumatic IVH depends more upon the severity of the brain injury rather than on the presence or absence of intraventricular hemorrhage.

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The authors report on the surgical treatment of 3 cases of an extreme lateral lumbar disc herniation (ELLDH) and discuss the pitfalls in diagnosis and treatment. As an ELLDH exhibits a nerve root sign that is a level higher than the usual disc herniation, the condition may be misdiagnosed. In this regard, myelography is not useful for diagnosing an ELLDH, since the compression occurs at the distal level of the nerve root. Therefore, CT myelography is the best diagnostic tool, because it can depict an ELLDH at the level of foramen and thus evaluate the relationship between the nerve root and the herniated disc and the bone components. As for the surgical approach to be used, the authors recommend a medial approach under operative microscope, and an extended foraminotomy and a partial resection of the facet, with or without a hemilaminectomy, may lead to successful decompression of the involved nerve root. In the 3 cases that the authors describe, preservation of the facet proved possible. An ELLDH is more frequently seen in eldery patients than the usual herniated disc, so that when encountering what looks to be lumbar nerve root compression, one should be aware of this clinical entitiy.

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Presented are the findings of 19 brain tumor cases associated with sudden onset of symptoms resembling a stroke. The initial symptoms were sudden onset of headache, vomiting, and disturbance of consciousness, indicating heightened intracranial pressure. Characteristics of these patients included the following : 1) vague personality or mood changes were noted before the episode : 2) the incidence of rebleeding was high ; and 3) hemorrhaging was often provoked by medical intervention (e. g. during surgery involving other lesions or angiography) , or by a head trauma. The possible mechanisms that may have produced these symptoms include : 1) a slowly growing huge tumor or a tumor associated with marked, well compensated hydrocephalus upset the intracranial balance by causing a small hemorrhage : 2) a small hemorrhage may have increased the size of a tumor adjacent to the brainstem and caused severe symptoms, and 3) a massive hemorrhage may have instantly led to a lethal outcome.

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The positioning of intracranial hypertensive patients for treatment of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) varies among institutions and the optimal grade of head elevation is still under discussion. Reductions in intracranial pressure at head elevation have been noted both experimentally and clinically. However, since the reports suggested that CPP is a better predictor of outcome than ICP and that patients with a CPP of less than 40 mmHg have a poor prognosis regardless of ICP, we have to take CPP into consideration. The purpose of this study was to investigate the effect on the ICP, CPP and Pressure Volume Index (PVI) of 30゜ head elevated position in severely head injured patients. Twenty three severely head injured patients (GCS≤8) were involved in this study. All patients remained intubated, paralyzed and mechanically ventilated during the study. ICP was measured by fluid filled ventricular catheter connecting to a bedside monitor and the radial artery was cannulated for blood pressure measurement. The transducer level of both ICP and blood pressure were always referred to foramen of Monro. The CPP was calculated by the following equation : CPP=mean BP-mean ICP. Patients were positioned at O゜ head elevation first, then elevated to 30゜ and returned to O゜ head elevation again. Each position was maintained for exactly 15 minutes. Thirty two studies were performed among 23 patients. PVI at O゜ head elevation were obtained in all patients and PVI at 30゜ head elevation were obtained in 10 patients after 15 minutes head elevation. At the 30゜ head elevation, ICP was decreased in each study, however CPP was altered differently. Of the 32 studies were performed, the CPP of 12 studies were increased or remained unchanged and the CPP of 20 studies were decreased. The PVI was statistically lower in the patients whose CPP were increased or remained unchanged at 30゜ head elevation. We concluded that 30゜ head elevation benefits the patients those who have a tight brain (low PVI). Our data also showed that PVI was not altered by 30゜ head elevation, suggesting brain compliance remains stable during position change.

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Reported herein is a case of a cervical epidural abscess in a 69-year-old female who was hospitalized for quadriplegia and who underwent anterior cervical debridement with an autogenous iliac bone graft. Although the results of a plain cervical X ray were negative, magnetic resonance imaging (MRI) revealed an anterior epidural mass compressing the C4-C5 region that showed a decreased signal intensity on T1-weighted imaging (T1WI) but a markedly increased signal intensity on gradient echo imaging (GEI) . The disc signal intensity of the C4-C5 region was slightly decreased on T1WI but increased on GEI. Further the body signal intensity of the C4 and C5 region was also increased on GEI. Because of these findings the diagnosis was a cervical epidural abscess complicated by discitis and osteomyelitis. The patient underwent anterior cervical decompression with fusion, and the neurological results were satisfactory. The pertinent literature is reviewed and 9 such cases in Japan are discussed. The usefulness of MRI is stressed for selections anterior surgery as a means of treatment and methods of abscess curettage are discussed.

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The authors report a rare case of a meningioma that extended to the extracranial area through the internal jugular vein in a 38-year-old male. Neuroimaging of this patient, who had been admitted to hospital due to a headache and signs of a compressed disc, demonstrated the presence of a tumor. This tumor, which mainly occupied the right occipito-temporal region, was found to extend down to the C4 level within the internal jugular vein, through the tent and the transverse and sigmoid sinuses. Surgical treatment was performed in two different stages. By using a transjugular approach and combining a retromastoidal craniectomy after a radical mastoidectomy, the tumor, which extended from the sigmoid sinus and jugular foramen to the internal jugular vein, was totally removed and both the cochlear nerve and the labyrinthine artery were preserved. A subsequent histological study confirmed the tumor to be a typical meningothelial meningioma. Although a meningioma is known to extend extracranially by the way of the neural foramina in the skull base or by direct invasion of the skull or as a metastasis via vessels or the lymph nodes, as well as an ectopic extracranial growth of a meningioma, cases of an intravascular growth of the tumor, such as was encountered in this case, are extremely rare. Based on the authors' experience and a survey of the literature, it appears that this disease tends to occur in relatively young adults and no accompanying jugular foramen syndrome has been noted despite the fact that the jugular bulb is filled with the meningioma.

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A case of achondroplasia presented as sleep apnea and headache was successfully treated by occipital bone decompression without duroplasty. A 16-year-old boy was admitted to our clinic with complaints of a severe headache. His symptoms were probably due to the compression of the brainstem by the hypertrophied occipital bone at the level of the foramen magnum, because the V-P shunt performed at the age of six was still effective. He underwent a decompressive suboccipital craniectomy and C-1 laminectomy. We did not add the duroplasty because sufficient decompression seemed to have been achieved by the craniectomy only. His symptoms were relieved immediately after the operation, and his postoperative course was uneventful. It is concluded that the duroplasty, which may cause undesirable complications such as liquorrhea, is not always necessary for the decompressive surgery of achondroplasia, provided that satisfactory decompression is obtained with a craniectomy alone.

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The authors describe a case of subarachnoid hemorrhage due to the rupture of intracranial mycotic aneurysms and complicated by infectious endocarditis. The patient, a 46-year-old male with a mitral insufficiency, had a high fever that had persisted for 5 months. He was diagnosed as having infectious endocarditis, caused by α-streptococcus, and was being treated with Penicillin G and Amikacin. However, during this therapy he developed subarachnoid hemorrhage. Angiography confirmed that mycotic aneurysms were responsible for the hemorrhage and Penicillin G continued to be administered. However, 12 days after the initial bout of subarachnoid hemorrhage, aneurysmal rebleeding occurred and he died. The authors emphasize the difficulty of developing an effective strategy for managing ruptured intracranial mycotic aneurysms and discuss the treatment of this disease with a review of the pertinent literature.

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The authors report a case of 76-year-old man who was admitted to hospital for an evaluation of slight left hemiparesis and left hemianopsia. Three weeks later, the patient suddenly complained of neck pain and left hemiplegia. Right carotid angiography revealed an occlusion at the origin of the internal carotid artery. Thus, two boluses of 1.6 million t-PA units were immediately injected into the thrombosed internal carotid artery via a Tracker catheter. Subsequently, a posifibrinolysis angiogram showed revascularization of the occluded carotid artery : severe residual stenosis remained and percutaneous transluminal angioplasty was immediately performed. Later, a postangioplasty angiogram revealed a wide patency at the site of the previous stenosis. The patient then improved rapidly and was discharged 5 months later manifesting only a minimal motor disturbance of the left arm.

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