We studied changes in the activity of coagulation and fibrinolysis in 2 groups of patients-one with chronic subdural hematomas (CSH's), and the other with minor head injuries and age-related changes in normal subjects. In the first group of 64 patients with CSH's, we measured 4 parameters in hematoma contents : fibrinogen, D -dimer, α-2 plasmin inhibitor (A2PI) and plasmin-α2 plasmin inhibitor complex (PLN-A2PIC). No fibrinogen was detected in any hematoma sample, but in contrast D-dimer appeared in extremely high concentration. A2PI was present within normal values, but PLN-A2PIC showed a tendency to increase. The patients with CSH's were divided radiologically into 4 types, according to their X-ray absorption values in CT images : a high-density type, an isodensity type, a low-density type, and a layering type. In contrast to the CT findings, there was no significant difference in the fibrinolytic factors as measured by PLN-A2PIC and A2PI. From these results, local hyperfibrinolysis was found in the hematoma contents, but analysis of those fibrinolytic factors did not make it possible to evaluate the degree of fibrinolysis. At the time of surgery, we also collected peripheral venous blood to measure fibrinopeptide A (FPA) as an indicator of thrombin activity and fibrinopeptide Bβ 15-42 (FPB) as an indicator of plasmin activity. It was thus found that increased fibrinolytic activity occurred not only in the hematoma contents but also in the systemic blood. Furthermore, in several cases followed up postoperatively, plasma levels of FPB remained above normal, which may reflect persistence of accelerated systemic fibrinolytic activity. In the second group of 56 patients with minor head injuries, the FPA and FPB in venous blood taken within 1 week after injury were both elevated. Out of the 56 cases, 26 cases were followed up for more than 3 weeks after injury, and through CT scan, 11 out of the 26 cases showed subdural fluid collection. Although the cases followed up showed systemic hyperfibrinolysis with or without subdural fluid collection, it was learned that the systemic fibrinolysis was not affected by the presence of subdural fluid collection. Moreover, in one case, it was observed that subdural fluid collection developed into CSH, concurrent with a gradual increase in fibrinolytic activity. It was thus suspected that old people have a tendency of elevated fibrinolytic activity even without head injury. Therefore, in normal subjects, our plan was to examine age-related changes in the plasma levels of FPA and FPB. The plasma level of FPB showed a positive correlation with age, and fibrinolytic activity increase with age. It was thus concluded that systemic hyperfibrinolysis in old people may play an important role as one of the causes of CSH's following minor head injuries and may explain why CSH's are common found in old patients.

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An electrophysiological study was carried out on the pain-related P250 in 19 cases of a persistent vegetative state. The pain-related P250 has the ability to assess the cortical responsiveness to painful stimuli directly and quantitatively without involving functions of the motor system. Among the 19 cases, 8 were treated by deep-brain stimulation (DBS) and 11 were not. As a result, the cases with a recorded pain-related P250 were found to show a strong therapeutic effect of DBS. A correlation was also noted between the improvement in the neurological symptoms and increased amplitude of the pain-related P250. It is inferred that the pain-related P250 represents a useful tool for assessing the indications and therapeutic effects of DBS in patients in a persistent vegetative state.

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A comparative study of the safety and effectiveness of subdural tapping and aspiration (TA) as a method for treating a chronic subdural hematoma (CSDH) in elderly patients versus conventional burr hole irrigation and drainage (ID) treatment has been evaluated. Results revealed that the TA method is the better treatment of choice because it is simpler, less invasive, results in fewer postoperative complications, and a shorter hospitalization period. Further, the partial removal of the hematoma by the TA method may accelerate the absorptive process of a well developed CSDH. This study has thus confirmed that a TA for aged or high-risk CSDH patients is a safe and effective alternative to a conventional ID.

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The effect of phorbol ester, 12-deoxyphorbol 13-isobutyrate (DPB), on the contraction of isolated vascular smooth muscle in canine basilar artery was examined. The muscle tension and cytolic Ca^<2+> level ([Ca^<2+>]_i) were recorded simultaneously using fura-2. Ca^<2+>-free solution was made by removing Ca^<2+> and adding 0.5 mM EGTA to physiological salt solution (PSS). Contraction was induced by high K^+ (72.4 mM) and DPB (10^<-6> M). High K^+ induced sustained contraction with a sustained increase of [Ca^<2+>]_i in PSS. DPB induced sustained contraction, although it induced only a transient increase followed by a decrease in [Ca^<2+>]_i below the resting level. The tension induced by DPB was greater than that induced by high K^+. Diltiazem inhibited the transient increase of [Ca^<2+>]i. In Ca^<2+>-free solution, high K^+ did not induce contraction, suggesting that high-K^+-induced contraction was dependent on the increase in [Ca^<2+>]_i. DPB induced transient contraction, the maximum tension of which was similar to that in the presence of Ca^<2+>. In Ca^<2+>-free solution, [Ca^<2+>]_i decreased below the resting level and DPB did not change [Ca^<2+>]_i, suggesting that the transient contraction was not due to the release of Ca^<2+> from cellular stores. The transient increase of [Ca^<2+>]_i induced by DPB was inhibited by diltiazem and disappeared in Ca^<2+>-free solution, suggesting that it was due to the influx of extracellular Ca^<2+> through a voltage-dependent Ca^<2+> channel. Conclusions : DPB induced sustained contraction in the presence of external Ca^<2+> and transient contraction in Ca^<2+>-free solution. These results suggested that DPB increases the sensitivity of contractie elements to Ca^<2+>, and small amount of [Ca^<2+>]_i is necessary for the sustained contraction induced by DPB.

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According to recent reports, the prognosis of diffuse brain injury with prolonged coma = diffuse axonal injury (DAI), as defined by Gennarelli, is often good in young cases. A total of 102 DAI cases were divided into two age groups. Group A, aged 29 or younger, and Group B aged 30 or older were studied in terms of neurologic symptoms. neuro-imaging and long term outcome in order to elucidate factors which might be related to a good outcome in younger cases. The long term outocome was evaluated in terms of activity of daily life (ADL) after 12 months or more following injury. Overall, recovery was significantly better in Group A than in Group B. As regards the level of severity of injury, the percentage of cases in Group B increased in proportion to the injury severity grade as determined by clinical symptoms upon admission. Computed tomography (CT) and magnetic resonance imaging (MRI) were evaluated according to the scoring systems we established. CT results indicated that Group B tended to have more serious cases with higher scores and, concurrently , the prognosis in Group B cases with higher scores was poor. By contrast, recovery to ADLS I and II was achieved in 94.9% of Group A cases with lower scores. At the same time, similar recovery to ADLS I and II was observed in some cases with higher CT scores, and 85.7% of such cases were in Group A. In our sequential observation of the MRI scores, the score decreased with the passage of time, the decline being more rapid in Group A than Group B. When the MRI score was evaluated in combination with the CT score, prognosis was good in both groups when the scores remained low, but when one or the other scores were high, recovery to ADL II or more was observed only in Group A. The findings of the ^<123>I-IMP single photon emission computed tomography (SPECT) were semiquantitatively analyzed by means of the delta count percent (D-Co%) of a circumferential profile curve. We observed the D-Co% over a period of time, and it was noted to decrease with time in Group A, but it tended to remain high in many Group B cases. Recovery to ADL II or more was achieved in almost all cases of both groups in which the D-Co% and in which the CT scores remained low, while 75% of those cases having recovered to ADL II or better despite the presence of a high D-Co% or CT score were in Group A. When those cases with demonstrated ventricular dilatation on the basis of the cerebroventricular index (CVI) as calculated from a CT scan in the chronic stage at six months or more after injury were categorized as the dilated group and others as a normal group, almost all Groups B cases were in the dilated group, while the Group A cases were nearly equally divided into the dilated group and normal group. In the dilated group with extensive neural injuries, 81% of Group A were restored to ADLs I and II, but all Group B cases remained on ADL III or less. These findings implied that good prognosis in younger DAI cases as compared with the controls could be attributed to a lower incidence of brain shearing injuries due to acceleration, a superior recovery mechanism owing to collateral sprouting, and inclusion of such cases as those that may present a transient neuro-dysfunction due to cerebral edema and others despite the presence of few neural injuries.

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Authors report a case of odontoid type II fracture with an irreducible posterior dislocation successfully treated by one-stage transoral resection of the dens and posterior cervical fusion. A 5:8-year-old woman fell down from a bicycle and had a bruise in the right forehead. She had an immediate tetraparesis with greater weakness in the upper extremities. Radiographic studies revealed an odontoid type II fracture with IJO mm posterior displacement of the atlas and the odontoid process. MRI demonstrated posterior displacement of the spinal cord due to the dislocation. She was placed in halo tongs with up to 10 kg of cervical traction for 15 days, which could not achleve anatomical alignment. On the 16th hospital day, transoral resection of the dens and posterior wiring with aLltOlogoLIS bone fusion was performed. We placed a bone plug between the laminae of C1 and C2, put a stainless buckle plate on the graft and wired them into position. After operation, a halo vest was applied for eight weeks. The patient did well postoperatively. Dynamic flexion and extension roentgeno-grams of the cervical spine revealed stability. We concluded that the one-stage transoral resection of the odontoid process and posterior C1/C2 fixation was a useful treatment for irreducible odontoid type II fracture with a posterior dislocation.

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The authors report the case of a 47-year-old man with a cerebral arteriovenous malformation (AVM) that completely disappeared within a period of 9 years. During this period he had been completely asymtomatic and received no treatment for 6 months except anticonVulsants. At the time of the initial carotid angiography in 1981, a large AVM was seen in the parietal lobe that was being malnly fed by the left callosomarginal and pericallosal arteries of the left anterior cerebi-al artery. The patient refused to undergo an operation because the site of the lesion was in the dominant hemisphere and because the postoperative morbldity from this surgery was high. Nine years later, Ieft carotid angiography showed the complete disappearance of this AVM and reduction in the size of the previous feeding arteries, however a computerized tomographic scan revealed that a small enhanced mass was still present. The patient has had no further epileptic episodes and only mild mLISCLllar atrophy remains in the right lower extremity.

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Reported is a rare case of a renal cell carcinoma that was found to have solitarily metastasized to the choroid plexus in the right lateral ventricle. Patient was a /~8-year-o]d male who was admitted to hospital on May 16, 1993, because of a consciousness disturbance. His past history included a left nephrectomy due to a renal cell carcinoma that had been performed 4 months before admission. CT scans revealed a mass of a high density in the right lateral ventricle trigone with intratumoral and ventricular bleeding that showed a homogenous enhancement on the use of a contrast medium. On T1-weighted Gd-DTPA enhanced MR imaging, this mass appeared as an area of low intensity, and on T2-weighted imaging, as an iso-intense area. Further, a right carotid angiogram showed a tumor with staining, being fed by the right anterior choroidal artery. A stereotactic needle biopsy showed a metastatic brain tumor of the renal cell car-cinoma. A solitary brain tumor metastasis of the choroid plexus is quite rare, and only 9 cases, including this case, have been reported in the literature. The authors discuss the clinical and radiological features of this case.

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Repcu~ted is a case of a fcn~eign-body granuloma that caused repeated convulsions after a craniotomy.In August 1992, the patients a 62-year-old female, had undergone surgery at another hospital due to severe intracranial bleeding. Following this surgery, her condition was fine for a 5-month period. However, from January through March 1993, She began experiencing repeated convulsive attacks. On coming under the authors' care, CT scans showed a small area of high density in the right posterior temporal lobe. Further, on MRI inspection, this small area enhanced heterogeneously, whereas it had not shown any CT enhancement. Thus, this small area was entirely extirpated. A histological study of a resected specimen led to diagnosis of a foreign-body granuloma that had been caused by a microfibrillar collagen hemostat (MCH, AviteneR ) . After this surgery, the convulsive attacks disappeared. Based on this experience, when performing a craniotomy, care should be taken to the use and the washing of the MCH.

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The authors report the case of a 57-year-old man with a solitary cerebral metastasis from a renal cell carcinoma that occurred 11 years after a nephrectomy. The brain metastasis was removed and no metastases were seen to other organs. Eight months after this brain surgery, the patient is alive and doing well. Further, his proliferating cell nuclear antigen labelling index value is very low. In a review of the literature, which includes this present case, only 9 cases of brain metastases from a renal cell carcinoma with latency period greater than 10 years after a nephrectomy have been reported. Eight cases that presented a solitary brain metastasis had good outcomes whereas one case of a multiple m:etastases had a poor outcome. The long interval of latency, extending from the nephrectomy to a symptomatic brain metastasis, may be attributed to the following mechanisms : (1) the slow-growing characteristics of a renal cell carcinoma, and (2) the possibility that there might have been a minute brain metastasis before the nephrectomy and that this metastasis grew very slow1y. Surgery is the recommended treatment for patients who develop a solitary brain metastasis from a renal cell carcinoma after a long disease-free interval, provided that there are no other metastatic lesions.

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Reported is a case of a 44-year-old man who developed an intracerebral hematoma of the right temporal lobe. Angiography failed to reveal any vascular abnonTlalities except for the presence of the mass. The hematoma was evacuated through a craniotomy, at which time many small vessels were noted in the surrounding white matter and the wall of the hematoma. These vessels connected to the subependymal veins of the inferior horn of the right lateral ventricle. Histologically, these vessels had smooth vascular muscles without internal elastic laminae, indicating venous channels. Thus, based on these finclings, the vascular lesion was diagnosed as being a medullary venous ma]forma-tion. In the diagnosis of a medu]lary venous malformation, it must be kept in mind that angiography does not always visualize the radiological findings. Therefore, the importance of the operative findings and careful macro- and micro scopic examinations of the resected specimen are stressed.

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Endocrinological changes of the hypothalamic, pituitary, and adrenal systems in children up to the age of 15 years have been studied in 30 cases of a minor head injury that caused vomiting. At the time of vomiting, the serum levels of ADH (antidiuretic hormone), ACTH (adrenocorticotropic hormone), cortisol, renine, epinephrine, norepinephrine, and the keton body were found to be high. These levels returned to their normal values, however, after vomiting ceased. The abnormal endocrinological changes that were detected in this study are similar to the endocrinological changes seen in children who manifest cyclic, acetonemic vomiting.

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