The authors have carried out a retrospective study of diffuse brain injury patients to determine if, based on the clinical findings on admission, a prognostic scale of their outcomes could be established. The subjects consisted of 79 diffuse brain injury patients that were admitted and treated at the authors hospital from April, 1987 to April, 1991. Using the Glasgow outcome scale, the outcomes of these 79 cases were as follows : 43 showed a good recovery, 22 had a poor outcome, and 14 ended in death. The items investigated as outcome-predicting factors were the correlations between the outcome and age, the neurological findings (consciousness, pupil movement, brain stem response), the neuroradiological findings (extent of the skull fracture, the amount of diffuse brain swelling, the depth of the lesion, the patency of the cisterns, with or without a subarachnoid hemorrhage (SAH), the extent of injury to the corpus callosum and the primary brain stem, and the presence of intraventricular hemorrhaging), as well as the general condition of the patients on admission, such as the blood pressure, the pulse rate, and the results of an arterial blood gas analysis. Based on chi-square evaluations, the factors that indicated a favorable prognostic outcome were as follows : i ) the patient was under 30 years old ; ii ) there was no skull fracture, iii) the patient had a Glasgow outcome scale of more than 7 ; iv) the bilateral pupils were of normal size ; v ) the brain stem reflexes were responsive ; and vi) the cisterns were patent and there was no SAH. In contrast, the factors that indicated an unfavorable prognostic outcome were CT scans that showed i ) a direct, primary brain stem injury, and ii ) diffuse brain swelling in adults. With regard to the patient's general condition, unfavorable prognostic factors were metabolic acidosis in patients with a simple head injury, hypotension below 90 mmHg systolic, and severe bradycardia or tachycardia in patients with multiple, deep seated lesions. However, a simple corpus callosum injury or an intraventricular hemorrhage did not affect the prognosis. Based on these findings, the authors have established a prognostic scale that will be clinically used for evaluating diffuse brain injury patients on admission.

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Authors have developed a new, practical method to reconstruct cerebral surface anatomical images for better surgical orientation and surgical planning. Using a personal computer and a commercially available image handling software, an area encompassing the surface gyri and sulci is selected from the most superficial slice of T1-weighted MR images, after which this selected area, on adjusting the alignment, is overlayed onto the next superficial slice. By repeating this procedure for 4 to 7 times, the brain surface image obtained clearly displays the gyri and sulci. A vascular image of the cerebral surface can also be obtained by this same method by using T2-weighted images or MR angiograms. Then, by combining both the brain surface and vascular images, an anatomically reconstructed image of the cerebral surface is achieved. The outlines of the lesion or ventricles can also be added, if necessary, and the entire procedure takes an hour or less. The authors believe that this method is superior to conventional surface anatomy scanning for discriminating anatomical structures close to a lesion. This surface anatomical imaging method has been used for the surgical planning and its use helped to minimize surgical damage to the eloquent areas.

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Radiosurgical dose planning for cerebral AVMs requires an accurate definition of the true tridimensional size and shape of the nidus. In this regard, it is difficult to define the accurate configuration of the nidus by conventional stereotactic angioglaphy alone. However, as stereotactic information from axial imaging has an important role to play in obtaining true tridimentional information of the nidus, for investigating 15 cases with cerebral AVM, treated by Leksell gamma unit at Chigasaki Tokushukai Medical Center, the authors have performed dynamic CT (D-CT) using ultrafast CT (Imatron C-lOO) with an intraarterial volus injection of a contrast material to delineate a more accurate configuration of the nidus on axial imaging. Further, the delineation of the nidus was also evaluated, especially the margin of the nidus in these images. In 12 of these 15 cases, D-CT clearly showed demarcated nidi. The margins of the nidi, however, were not clearly delineated in the remaining 3 cases, consisting of one case of an embolized AVM with polyvinyl alcohol, one case of a small AVM, and one postoperative case of feeder clipping. In 11 cases, we also compared the configuration of the nidus on axial imaging obtained by D-CT with that obtained by MRI. Demarcated nidi were clear in 10 of these cases (90.9%) by D-CT, and in 4 cases (36.4%) by MRI. In 7 cases, the difinition of the margin of the nidus by MRI produced questionable results, because of hemosiderin (n=3), gliosis and ischemic parenchyma (n = 2) and embolic material (n=2). Because Imatron CT visualized sequential images of the contrast medium from the feeders through the drainers, each vascular component of the AVM could be distinguished in detail and the margin of the nidus on axial imaging was clearly defined. In addition, it was also possible to analyze the AVM dynamics and define the true nidus by reviewing this information as recorded on the video tape. It thus was concluded that the dynamic CT using Imatron CT is very useful in planning radiosurgical treatment for AVMS and in some selected cases was found to be more reliable than MRI in accurately detecting the margin of the nidus.

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A new classification of congenital and infantile hydrocephalus was proposed in a hope of the correlation with the estimated prognosis, namely, "Perspective Classification of Congenital and Infantile Hydrocephalus". This classification is based on the multifactorial aspects affecting prognosis of congenital hydrocephalus. Three major concepts are included in the items ; clinico-embryological stage (Stage I-V), clinico-pathological type (Type P ; primary, Type D ; dysgenetic, Type S ; secondary) and clinico-chronological category (Category F ; fetal, Category N ; neonatal, Category I ; infantile) . This newly proposed classification may be valuable to the discussion on the controversial problems regarding the prenatal/perinatal therapeutic management of hydrocephalus offering more clearly identified hydrocephalic state together with the estimated postnatal outcome.

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The natural history and long-term outcome of an intracranial dissecting aneurysm is not well known, and this study was initiated to elucidate these issues. Fifty patients with an intracranial dissecting aneurysm of the vertebrobasilar system were retrospectively analyzed with regard to their clinical features, angiographical findings, and their outcomes at six months and over a long term after onset of the aneurysm. Patients were divided into two groups : a subarachnoid hemorrhage (SAH) group (38 patients) ; and a non-SAH group that manifested ischemia and/or a headache (12 patients). The mean long-term follow-up period was 6.2 years. In the non-SAH group, the patients were younger and males predominated. In the SAH groups, the dissecting aneurysms were located more commonly at right vertebral artery. In both groups, the pearl and string sign was the most common finding on initial angiography. On follow-up angiography, an improvement in the arterial configuration was more frequently seen in the non-SAH group. The clinical features and the angiographical findings differed between the groups. In the SAH group, 27 patients (71%) were surgically treated, whereas in the non-SAH group, only 3 patients (25%) underwent surgery. In the SAH group, the six-month outcomes varied but correlated well with the clinical severity [Hunt and Kosnik grade] on admission. In the non-SAH group, the six-month outcomes were generally satisfactory, and the long-term outcomes were also favorable, with all patients, excepting one, having returned to work on long-term follow-up investigation. Based on their findings, they stress that surgical intervention should be decided prudently, because conservative treatment resulted in the successful recovery of many patients, even those with a subarachnoid hemorrhage.

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The authors discuss the case of a 9-year-old boy who was admitted to hospital on February 29, 1992 because of persistent right hemiparesis, motor aphasia, and mental retardation. On August 11, 1991, he had sustained a cerebral infarction with right hemiplegia and total aphasia and had been diagnosed as having moyamoya disease. Thus, on October 11, 1991, he underwent a left encephalo-duro-arterio-synangiosis (EDAS), but his neurological deficits did not significantly improve. Because of this failed EDAS, a vascular reconstruction was performed at our institution, and the superficial temporal artery that was used for the EDAS was stripped from the cortical surface and anastomosed to the central artery, which had a diameter of about 0.2 mm. Postoperatively, marked improvement was noted in his hemiparesis, motor aphasia, and mental retardation. In summary, based on the results in this case, surgical revascularization is thought to be needed even in childhood moyamoya disease cases that are complicated by a major stroke.

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When patients with brain tumors show the onset of a stroke, we are apt to suspect an intracerebral hemorrhage of tumor origin. However, cases of intra-axial tumor with stroke symptoms due to cerebral infarction are rarely encountered. We report a 67-year-old male who displayed an acute onset of left temporo-parieto-occipital infarction and astrocytoma (grade 3) was detected in the left frontotemporal lobe. Neuroradiological images on CT, MRI and angiography mimicked the findings of multicentric glioma.

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The authors report a rare case of a dumbbell-shaped cervical neurinoma that extended to the anterior cervical region in a 51-year-old man. The subject was admitted to hospital because he had noted a right anterior cervical tumor and hypesthesia that had developed in his right hand. Subsequent MR imaging revealed a dumbbell-shaped tumor at the C1-2 level that exteded to the right anterior cervical region. Further, an angiogram showed a stained tumor that was being fed by the right vertebral artery. Total removal of the tumor was successfully accomplished by a two-stage operation : first, using a posterior approach, the intraspinal and laterally extended portions of the tumor were extirpated, then, after an interval, using an anterior approach, the anterior portion of the tumor was removed. After the first operation, the patient was confined to bed for only a week, and later, he had to wear a Philadelphia poly-neck collar whenever ambulatory for one month.

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The authors report the case of an 11-year-old girl who was admitted to hospital on November 4, 1992 because of persistent quadriparesis, motor aphasia, and mental retardation. On January 1, 1984, she had had a cerebral infarction and was diagnosed as having moyamoya disease. She thus was surgically treated and underwent a bilateral encephalo-myo-synangiosis (EMS). Postoperatively, however, the patient did not show any improvement. On November 4, 1992, because of failure of the left EMS, she again underwent surgery for a vascular reconstruction. Since the previous horse shoe incision on the left side had the left parietal branch of the superficial temporal artery (STA) and the posterior auricular artery (PAA) with too small a diameter (0.3 mm) and too short a length, 3 cm of the STA was interposed between the PAA and a branch of the left middle cerebral artery. After this surgery, a slight improvement was noted in the motor weakness of the right upper extremity and the motor aphasia. In this report, the authors also introduce vascular reconstruction techniques for a failed EMS.

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The authors report a rare case of late brain abscess that appeared 54 years after a head injury. Two days before admission, a 60-year-old female had complained of weakness and clonic spasms of the left hand. During clinical investigation, it was found that she had a history of an open head injury at 6 years old, but no further symptoms had occured for the past 54 years. She had no previous disorders that may have caused the brain abscess, such as a heart disease, paranasal sinusitis, tympanitis, bronchitis, or an immune deficiency. Further, laboratory examinations revealed no abnormality except for a mildly elevated C-reactive protein level. CT scans and MRI revealed a ring-like enhanced mass lesion in the right frontoparietal region just below the site of a depressed fracture that had resulted from the early fracture. Subsequent CT scans showed growth of this lesion. Thus, this lesion was totally resected and was confirmed to be a brain abscess. Staphylococcus aureus, which had high sensitivity to many antibiotics, was detected in the abscess, and it is thought that this bacterium in the circulating blood had entered the scar tissue.

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Intraoperative angiography during clipping operation using a radiolucent head fixation system is reported. The radiolucent head fixation system, multipurpose head frame and head holder, was developed for intraoperative CT scanning. The intraoperative angiography was performed in a case with basilar bifurcation aneurysm by retrograde transbrachial catheterization of the left proximal vertebral artery. It confirmed complete obliteration of the aneurysm and preservation of the parent and surrounding arteries intraoperatively.

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An autopsy case in which a vertebral artery was tortuous and compressed the 6th cervical nerve root was reported. This case was a cadaver which died of stomach cancer at 81 years of age. No history of his neurological status was available. His right vertebral artery was emerging out of the transverse foramen of the sixth cervical vertebra to run medially and posteriorly, compressing heavily the underlying cervical nerve root covered by dura mater. It was located closely near by the posterolateral edge of the uncus of the sixth cervical vertebra. The present case showed a possible hazard of damaging vertebral artery during the surgery such as removing degenerated cervical discs. We should be aware of possibility that the vertebral artery may sit nearby the disc to be operated upon and lead to fatal complication by injuring it.

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A case of a penetrating intracranial injury through the cranial vault of a 2-year-old girl is reported. The child was playing with a pair of scissors when she stumbled and fell on them accidentally. The scissors penetrated into the left temporal region. On admission, she was alert and had no neurological deficits. Plain X-ray of the skull revealed that the scissors had penetrated into the intracranial space. We decided that it would be very risky to remove them blindly, thus, we removed them by a small craniectomy under general anesthesia. The tip of the blade passed near the middle meningeal artery and the sylvian vein. Fortunately, no bleeding occurred. The repair of the dura mater was performed using her own temporal fascia. The postoperative course was uneventful, and she was discharged with no observable neurological deficits.

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