The effect of an administration of amino acids, including branched chain amino acids on the general metabolism has been evaluated in a study of two groups of patients with an acute-stage, ruptured, intracranial aneurysm. The intravenous alimentation for Group 1 (9 patients) consisted of 3,000 ml/day of water, 150 mEq/day of Na^+, 60 mEq/day of K^+, and 261 g/day of glucose, whereas for Group 2 (8 patients) , the regimen consisted of 3,000 ml/day of water, 120 mEq/day of Na^+, 68 mEq/day of K^+, 180 g/day of glucose, and 58.7 g/day of amino acids. In Group 1, a significant decrease was noted in body weight, the triceps subcutaneous fat content, the arm muscle circumference, and the total protein and albumin values, in contrast to these same parameters in Group 2. Similarly, in the Group 1 patients, the prealbumin, transferrin (a rapid turn-over of protein) and Fisher's ratio also showed a decrease. Further, a marked improvement in the nitrogen balance was noted in the Group 2 patients. In both groups, however, the metabolic expenditure at rest moderately increased following the subarachnoid hemorrhage and it further increased after the surgery. Also, the cellular immunity decreased in the two groups. In summary, the administration of amino acids decreased protein catabolism and demonstrated a protein-sparing effect in patients with an acute-stage, ruptured, intracranial aneurysm.

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From 1979 to 1990, 223 patients with cerebral arteriovenous malformations were surgically treated by authors. Among these, 196 patients with totally resected AVM were followed for mean duration of 5.3 years. Their record were reviewed with special focus on the preoperative seizure history and follow-up seizure status. The authors observed the onset of new seizures in 21 (16.3%) of 129 patients who did not have seizures before surgery. Among these, however, 9 had only one or two seizures during the early postoperative period, and the other 12 had only rare persitent seizures that were well controlled with medications. Among 67 patients with preoperative epilepsy, 35 (52.2%) experienced no seizures for more than 2 years after surgery and 20 of them were receiving no anticonvulsant medication. Among 32 (47.8%) patients who continued to have seizures, the frequency of seizures improved in 10, remained unchanged in 18 and was worse in 4. There was a statistically significant relationships between the duration of preoperative epilepsy and the postoperative seizure status. The patients whose seizure duration was one years or less had a better chance to improve their seizures than the patients with a seizure history of more than one year. The author's conclusion is that the risk of persistent epilepsy after surgery is small in those patients who did not have seizures preoperatively, and that preoperative epilepsy has a strong tendency to improve after excision of the AVM.

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For the treatment of moyamoya disease in children, the authors describe a new omental transplantation technique to the brain that was used to treat 10 patients, who presented repeated transient ischemic attacks or fixed neurological deficits due to ischemia in the territory of frontal or occipital lobes. Briefly, We performed an end-to-side anastomosis of the gastroepiploic artery to the superficial temporal artery (STA) or occipital artery (OA) , after which the distal end of the STA or OA was ligated and resected. Also, an end-to-side anastomosis of the contralateral side of the gastroepiploic vein to the cortical vein was performed. Therefore, by using this technique, the structure passing through bone window was restricted only to STA or OA, so that mechanical compression of the anastomotic site was avoided at the time of skin closure. Good patency was there by obtained in 9/10 cases (90.0%) by means of this new technique, in contrast to 10/32 cases (31.3%) when the standard technique was used (χ^2-test, p<0.002) . It thus has been concluded that for moyamoya patients, this new technique is very useful for treating ischemia of the frontal and occipital lobes.

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Stereotactic radiosurgely has been used to obliterate arteriovenous malformations (AVMs) and to judge the efficacy of this technique, follow-up angiography and magnetic resonance imaging (MRI) has been used to assess the results in AVM patients given this therapy. Of 60 patients who received this therapy, angiography was used to follow the postoperative results in 37 patients for over a year. Twenty-nine patients (78%) showed a good outcome, with 15 (40.5%) manifesting a complete obliteration and 14 (37.8%) a subtotal obliteration. The smaller the size of the nidus, the higher was the obliteration success. In those who showed a complete obliteration, the mean dose delivered to the AVM margin was 21.1 Gy. As for the effect of this therapy with respect to age, children showed higher obliteration rate than adults. Postoperative MRIs of 27 patients revealed radiation-induced edema in 8 (30%), and in only two of these 8 patients was this edema symptomatic. In those who showed radiation-induced edema, the mean dose delivered to the AVM margin was 19.8 Gy, the same dose that was given to the other patients. Based on these results, stereotactic radiosurgery was found to be a promising method to obliterate AVMs, especially those considered inoperable by other means.

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There are problems that are unresolved with regard to the treatment of cases presenting a post-traumatic cervical myelopathy, such as when the surgical indications are not clearly evident and the proper timing of this surgery. In this regard, the authors have used dynamic MRI to retrospectively analyze the cervical spine of 24 previously treated dynamic MRI cases presenting a subacute myelopathy to determine the efficacy of dynamic MRI as a method of treatment. Dynamic MRI analysis protocol was as follows. For the MR imagings, each patient was placed supine with the neck in the neutral position, after which the neck was set in the extended position. Dynamic changes between the neutral position and extended position images were analyzed by focusing on the following two points : 1) the narrowing of the subarachnoid space in the T2-weighted images and 2) evidence of cord compression in the T1 -weighted images. Twelve cases out of 24 were treated conservatively because of a gradual improvement in their myelopathic symptoms. The other 12 cases were treated surgically, because of no improvement in their residual myelopathic symptoms at the time when the dynamic MRI had been performed. In the majority of the cases in the surgical group, the narrowing of the subarachnoid space and spinal cord compression were heightened on neck extension, whereas in the conservative group, such findings were minimal. Dynamic MRI also more clearly visualized multiple lesions and the direction of the cord compression. These findings thus provided more detailed information to plan the surgical approach and to estimate the amount of surgical decompression needed. Based on the results of this retrospective study, we thus have concluded that surgical treatment appears to benefit subacute cases who show no improvement in their residual myelopathic symptoms and whose dynamic MRI results also demonstrate an increased narrowing of subarachnoid space and a heigntened spinal cord compression.

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To evaluate the capacity of the cerebrovascular reserve, the acetazolamide test must be used to quantitatively measure the cerebral blood flow (CBF) before and after the administration of acetazolamide. Previously, the authors have explained the rationale for using 5 min SPECT images to quantify the CBF with N-isopropyl-p-[^<123>I] iodoamphetamine (^<123>-IMP), and in this study they describe how they devised a ^<123>I-IMP double injection method for use with the acetazolamide test, and report on the clinical results. First, We measured the brain and arterial ^<123>I concentrations in 10 normal subjects after a ^<123>I -IMP injection, and noted that after 25 minutes the brain and arterial blood activity had plateaued and stabilized. Thus, by using the background substraction method, We found it was possible to quantitatively measure the CBF twice in 30 minutes and have called this technique the double injection method. We have clinically used this double injection method for evaluating the CBF in 5 lacunar stroke patients with no major arterial occlusion and found no statistically significant difference in the CBF values between the first and second CBF measurements. They then applied this double injection method for the acetazolamide testing of 10 stroke patients with an arterial occlusion or stenosis and found that the CBF results compared favorably with the CBF results achieved with the use of the separate injection method. It also should be noted that the double injection method was successfully used for clinical CBF measurements without acetazolamide testing.

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For degenerative diseases of the cervical disc, an anterior discectomy without a bone graft is the preferred procedure, since it allows for earlier recovery without complications that might arise from a bone graft. In this regard, from 1984 to 1992, a total of 45 patients received a microsurgical discectomy without a bone graft, and the authors have undertaken a study of the long-term clinical and radiographic results in 36 of these patients, the follow-up data consisting the results of neurological and radiographic exams (plain X-ray films and MRI) that were conducted between two months and 97 months postoperatively (mean : 37 months). The clinical results of surgery were evaluated and the recovery rate calculated on the basis of the Neurosurgical Cervical Spine Scale (NCSS) proposed by the Japanese Society of Spine Surgery. In this way it was found that the overall average recovery rate was 79.8%. Further, results revealed that all of the disc spaces that had been the operative site had narrowed, and that bony fusion had occurred in 86% of the cases within 2 years, and that no case had developed any instability at the operative site. Also, fusion with an anterior angulation was seen in 37% of the cases, and was more frequent in cases with a lesion in the upper cervical region that had undergone an operation that had preserved the preoperative disc space. No relation was seen between anterior angulation and the narrowing of the disc space, or instability or herniation that may have occurred at other levels. However, over a prolonger period, severe angulation could lead to future problems, such as the degeneration of other discs. Therefore, it is felt that cases presenting a single level lesion in the lower cervical area in which the disc space has already narrowed are good candidates for this type of surgery, since the incidence of d malalignment is less.

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The chest X-ray of a 15-year-old female, who exhibited no external symptoms, showed a left upper posterior mediastinal tumor. Chest CT scan and MRI showed that the tumor lay on the body of vertebra between the first and 6th thoracic levels with intraspinal extention through the intervertebral foramen at the 2nd, 3rd and 4th thoracic levels. Because of her religious convictions (a Jehovahs Witness) she refused to have a transfusion ; and this fact, coupled with the tumor extension, lead us in our decision to opt for a two-stage operation. For the first stage of the operation, the patient underwent laminectomy and resection of the intraspinal component of the tumor in the prone position on July 17th 1990. And for the second stage, the patient underwent thoracotomy and resection of the mediastinal component of the tumor in the right recumbent position on September 5th 1990. The tumor was dumbbell-shaped, and originated from the 3rd thoracic spinal ganglion. The histopathological diagnosis was that of a typical ganglioneuroma. The patient was discharged without having a blood transfusion.

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The authors report 2 cases of a postoperative intracranial hemorrhage in treated severe subarachnoid hemorrhage (SAH) patients due to a vitamin K (VK) deficiency. These cases are described below. Case 1 : The patient, a 48-year-old woman, was admitted to our hospital because of an SAH, and a neck clipping was soon performed after admission. On the 10th postoperative day, an epidural hematoma was found, and on the 17th postoperative day, a hemorrhagic infarction occurred. Case 2 : The patient, a 39-year-old man, was admitted to our hospital because of an SAH, and a neck clipping was soon performed after admission. On the 14th postoperative day, an epidural hematoma was detected. The concentration of the serum VK during an evacuation of the hematoma was found to have markedly decreased, and a coagulation examination revealed that a VK deficiency had caused the postoperative hemorrhage. A subsequent adnlinistration of VK resolved the hemorrhagic complications in both patients. The VK deficiency in these cases may have been caused by an increased VK consumption due to the pre-DIC state after the SAH and the invasive surgery, and the supression of VK production by intestinal flora because of long-term antibiotic medication. It thus has been speculated that in severe SAH patients, a VK deficiency may be the cause of a postoperative hemorrhagic complication.

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The authors report a rare case of a brain abscess following a cerebellar hemorrhage. The patient, a 71-year -old male, had been hospitalized because of the cerebellar hemorrhage. On admission, a neurological exam revealed disorientation and cerebellar ataxia, and a precontrast CT scan confirmed the cerebellar hemorrhage but no hydrocephalus. During the subsequent conservative therapy, the patient developed pneumonia. His fever continued and over the next few days his neurological condition rapidly deteriorated. A postcontrast CT scan showed a hypodense, ring-enhanced lesion with marked perifocal edema and hydrocephalus. Despite surgical intervention to treat the cerebellar abscess, his clinical course was poor. An abscess formation should be suspected when patients with a cerebral hematoma manifest developing symptoms such as a fever and/or disturbed conscious behavior.

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