The annual per-population incidence of subarachnoid hemorrhage (SAH) in Miyagi Prefecture has been calculated as being 17.0/100,000 recently. In order to determine whether changes have occurred in the overall SAH outcomes over recent years, we have analyzed the annual 1984 and 1991 SAH outcomes contained in a community-based stroke register in Miyagi Prefecture. From a total of 302 SAH cases for 1984 and 351 SAH cases for 1991, the complete clinical records of 268 cases and 321 cases, respectively, were extracted for this analysis. The male-to-female SAH patient ratio has shifted from 1 : 8 to 2 : 3 between the two studied years, and the average age has increased from 50.8 years to 53.4 years for males and from 58.2 years to 60.5 years for females. Further, the average pre-hospitalization period from SAH onset has shortened from 4.6 days to 2.4 days. The number of SAH cases with a poor grading, i. e., Grades 4 and 5 of Hunt & Kosnik grading, has increased from 19.8% to 27.1% and the number of Fisher's group 3 patients has similarly increased from 43.2% to 61.3%. In general, acute-stage SAH patients under 75 years of age with Hunt & Kosnik grading of less than Grade 4 underwent surgery in both years. In this regard, the number of SAH cases operated on within 3 days increased from 59.9% to 72.1%. As a result of earlier hospitalization and an increase in acute-stage operations, there was a decrease in presurgical aneurysmal reruptures from 36.6% to 29.1%, as well as a decrease in the incidence of symptomatic vasospasms, especially in Fisher's group 2 and 3 cases. On the contrary, no significant improvement in the surgical result was found between the two years (excellent 52.8% ; good 23.8% ; fair 14.5% ; poor 4.2% : and dead 4.7% for the 212 cases in 1984 versus excellent 54.4% ; good 18.3% ; fair 11.1% : poor 5.6% ; and dead 10.7% for 254 cases in 1991). Similarly, SAH cases given conservative treatment schowed poor outcomes in both years. This comparative analysis could not reveal any overall improvement in the SAH outcomes. However, the increase in the unmber of SAH cases involving older patients and a poor grade seemed to be counterbalanced by a decrease in reruptures and symptomatic vasospasms, due to earlier hospitalization, increased acute-stage operations and advances in perisurgical SAH management.

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To investigate the overall management results of moribund cases of a subarachnoid hemorrhage (SAH), 225 consecutive patients who were admitted to the Emergency Medical Center of Kyorin University from 1989 to 1993 were retrospectively analyzed. About half of these patients were hospitalized within one hour from the onset of the hemorrhage and 95%o within 6 hours. Their neurological condition on admission was categorized according to the Hunt and Kosnik grading scale, with 17% of the patients assigned to grade 4 and, 640.vo assigned to grade 5, respectively. About 40% Of the patients manifested abnormal pupillary findings and also presented ataxic or apneic respiratory pattern on admission. Among this studied patient-population, 24% of the patients were admitted in the"dead on arrival"condition. The SAH diagnosis in 80% of the patients was achieved on the basis of their CT findings, and the balance on the basis of a postmortem spinal or suboccipital cisternal puncture. A ruptured aneurysm was verified in 460/0 of all patients and radical surgery was accomplished in 34% of all patients. The overall management mortality amounted to 75% and a favorable outcome was achieved in 14% of the patients. The major causes of a poor outcome were primary brain damage due to a rupture of the aneurysm, rebleeding from the aneurysm, and/or acute respiratory failure. The prognosis of patients who had ischemic events after the ictus was definitely worse, and their mortality rate was more than 90%. Based on these findings, the authors have concluded that conventional management yielded a limited outcome and that only prophylactic treatment of an unruptured aneurysm has the possibility of improving the overall prognosis of a SAH.

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To settle the controversy over optimum management strategy for patients with poor-grade (Hunt and Hess grade IV and V) aneurysmal subarachnoid hemorrhage (SAH), the medical records of 50 patients admitted with poor Hunt and Hess grade have been examined retrospectively with literature review. Initial findings such as better neurological condition (Hunt and Hess grade IV) and presence of intracerebral hemorrhage were indicators of good prognosis. Patients with intraventricular hemorrhage and uncontrollably increased intracranial pressure (>40 cm H_20 after extraventricular drainage) resulted in severe morbidity or mortality. Regarding the timing of surgery, early intervention led to a better outcome with less morbidity because of the marked decrease of the severity of vasospasm and the incidence of rebleeding. The frequency of intraoperative premature rupture and the overall mortality were not significantly influenced by the timing of surgery. It is concluded that, for patients in poor Hunt and Hess grade without a definite evidence of irreversibility such as brainstem failure signs or uncontrollably increased intracranial pressure, early surgery followed by aggressive treatment to prevent cerebral vasospasm is the treatment of choice.

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A retrospective analysis has been conducted of the overall management of 262 subarachnoid hemorrhage patients with a WFNS grading of IV and V. The patients were divided into two groups according to their hospital admission: 143 patients who were the former group treated from 1981 through 1986, 119 patients treated from 1987 to 1993. Of the 143 cases in the former group and the 119 cases in the latter group, 87% were admitted to hospital within 24 hours and 93% within 72 hours after their hemorrhage. These cases amounted to one-third of all cases of an aneurysmal subarachnoid hemorrhage during the two periods. The outcome of the conservatively treated cases was poor both in the grade IV and V patients: one case was left with a severe disability, two have survived in a vegetative state, and the others died. In the grade IV, patients of the latter period, the overall outcome was better. Also, cases that had a poor outcome caused by a vasospasm or an operative complication due to other than the severity of the attack were fewer among patients treated during the latter period. The grade IV cases were divide into two subgroups, based on the Glasgow Coma Scale (GCS) GCS 11 and 12 cases with a good outcome and GCS 7 to 10 cases with a poor outcome. For grade V patients, the outcome was poorer than for the grade IV patients, and these outcomes were about the same between the two treatment periods. Most of the cases with a poor outcome were due to the severity of the hemorrhage. Further, the outcomes were poor for most of the cases who underwent surgery more than 8 hours after the attack and for all cases with a CT score greater than 10. Based on these findings, it thus has been concluded that the outcomes of the grade IV patients can be improved due to the progress that has been made in operative procedures and in treating vasospasms. However, no improvement in the outcomes of grade V patients can be expected because of the severe brain damage that occurs due to hemorrhage. Any predicting factor for favorable outcome could not be found in grade V patients.

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In reconstructions of complicated defects of the scalp, skull and/or skull base, a free tissue transfer with a microvascular anastomosis has proven to be very effective. In this paper we describe free tissue transfers provided for 9 cases manifesting postoperative complications requiring reconstruction. Seven of these cases underwent a scalp reconstruction and the remaining cases underwent a skull base reconstruction. The free flap used were a radial forearm flap (2), a latissimus dorsi muscle flap with a split thickness skin graft (2), a latissimus dorsi myocutaneous flap (2), a rectus abdominis myocutaneous flap (1), an omental flap (1), and a combined serratus muscle flap and a latissimus dorsi muscle flap with a split-thickness skin graft (1). The postoperative course of these cases was uneventful, except for minor additional treatment that two cases required. The latissimus dorsi muscle flap and rectus abdominis myocutaneous flap were found to be suitable for the repair of large scalp defects and skull base reconstructions. The radial forearm flap was found to be well adapted for reconstructions of the hairline. In these reconstructions, the superficial temporal artery and vein were mainly used to supply the recipient vessels. Vascular anastomoses were performed in an end-to-end fashion, no trouble with the vascular pedicles occurred. To detect and prevent flap necrosis and/or an intracranial infection, postoperative monitoring of the flap is necessary.

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Since the installation of Gamma-knife, we have treated 26 cases of AOVM (angiographically occult vascular malformations), who had enough follow-up period more than 12 months. There were 16 males and 10 females, whose age ranged from 3 to 58 years old with an average of 32.7. Their clinical presentations at the onset were hemorrhage in 17, seizure in 7 and progressive neurological deficits in 2. Three cases had multiple lesions of AOVM. Among 26 symptomatic lesions, 15 were located supratentorially, 7 in brain stem and 4 in cerebellar hemisphere. AOVMS were treated with radiosurgery at the marginal doses between 15 to 20Gy (mean 17.9Gy). Follow-up studies revealed a rebleeding in one after the treatment in the mean follow-up period of 17.7 months. Among 7 cases presented with seizure, 5 were improved and the other 2 showed no change. Imaging studies with MRI showed a major shrinkage in 1, minor shrinkage in 7 and no obvious change in 18. Symptomatic perifocal edema occurred in 5 (19.2%), especially those who were treated at the marginal dose more than 18Gy. In conclusion our preliminary clinical results indicate that the radiosurgery with Gamma-knife has positive effects to prevent the rebleeding and to control the seizures associated with symptomatic AOVMs.

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Generally speaking, the customary technique for surgery involving the posterior fossa is a craniectomy, involving the use of a craniotome. However, there are difficulties in using a craniotome because of the narrowness and depth of the posterior fossa, and fear that the procedure may cause uncontrollable bleeding from the dural sinus. Using a different approach, we have successfully performed 34 safe osteoplastic craniotomies of the posterior fossa by means of a reliable technique that involves creating two keyholes just on the sigmoid sinus and the use of a chisel and a wire saw instead of a craniotome. In all cases with this technique, the results have been satisfactory. An osteoplastic craniotomy is a more natural surgical approach than a craniectomy, especially for children, since the psychological effect of this surgery on the patient is lessened and such postoperative complications as subgaleal fluid collection due to CSF leakage are prevented. Further, an exploratory reoperation, if required, is easier to perform. In contrast to a craniotome, a chisel is more compact and easier to manipulate. Also, it can create any size and shape of required bone flap that has been found to possess excellent stability after replacement. Even in areas where cutting with a craniotome can cause problems, e. g., in the frontal and temporal base and the sphenoidal ridge, a chisel provides a safer alternative. Apart from the posterior fossa, we have also confirmed the advantages of using a chisel for neurosurgery involving the supratentorium.

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Changes in platelet aggregation (PA) were investigated in patients with carotid stenosis before and after carotid endarterectomy (CEA) to have information for reducing perioperative complications. Reduction of adenosine diphosphate (ADP)-induced PA was noted in the groups receiving preoperative ticlopidine (T) and aspirin (A). Collagen- and adrenalin-induced PA were also reduced in group A. On the contrary, collagen-induced PA in the groups receiving no medication (N) and warfarin (W) showed higher values than those of normal subjects. Collagen-induced PA was also still higher than the levels found in normal subjects in the N and W groups postoperatively, and such a hyperaggregable state continued for on and/or two weeks after discontinuation of the medication. In the A and N groups, adrenalin-induced PA was continuously reduced for one week postoperatively. The elevation of collagen-induced PA in the early postoperative stage following CEA was thought to be related with the operative exposure of collagen fibers of the vessel wall to the blood stream. Our data suggested that administration of aspirin would be suitable for the prevention of a thrombo-embolic episode in the perioperative stage of CEA. However further examination is needed regarding the suppressive effect on endothelial regrowth, which may be caused by aspirin administration.

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The preventive effect of nifedipine (Adalat^<(R)>) on delayed ischemic deterioration (DID) and angiographically detected vasospasms has been assessed in 72 patients presenting with grade 2 to 4 aneurysmal subarachnoid hemorrhage (SAH) on admission (Hunt and Kosnik classification). All patients underwent acute surgery within 72 hours after the SAH. For 44 patients, a sublingual administration of nifedipine (10 mg) was commenced immediately after the diagnosis of SAH and was continued every four hours for at least 14 days. Nifedipine treatment commenced on admission was found to be associated with a good prognosis for patients with a Grade 2 SAH classification and significantly lowered the occurrence of angiographically detected vasospasm and DID in comparison to a control group not given nifedipine treatment. Of 18 patients given nifedipine treatment, platelet aggregation, which was measured from 7 to 14 days after the SAH, decreased in 15 patients (83.3%), and DID was found to occur more frequently in patients showing an insufficient inhibition of platelet aggregability. Measurement of the nifedipine blood levels in 10 patients revealed that the nifedipine concentration peaked on the third day of treatment and then declined in all patients. In 2 patients manifesting DID, the nifedipine concentration showed the steep decrease after the third day of treatment. These results seem to indicate that nifedipine is effective in preventing angiographically detected vasospasms and DID, and that the inhibition of platelet aggregability may be involved in this preventive effect.

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Spontaneous spinal extradural hematoma is uncommon. An early diagnosis and immediate surgical treatment are important to prevent severe neurological deficits such as paraplegia. The authors reported a case of thoracic level hematoma. Preoperative emergent magnetic resonance imaging (MRI) informed us of correct diagnosis and extension of extradural hematoma. Emergent operation relieved the patient's neurological deficits promptly. A healthy 52-year-old male developed severe back pain followed by progressive weakness in his legs. On admission, neurological examination revealed paraparesis, sensory disturbance below the Th5 dermatome and urinary and fecal disturbance. The myelogram showed blockage at Th3 and postomyelographic computed tomography disclosed an iso-density mass in the dorsal side of the spinal canal. MRI showed an extradural hematoma as a hyperintense mass extending over Th2 and Th3. Nineteen hours after the onset of symptoms, laminectomy from Th1 through Th3 and evacuation of hematoma was performed. A dilated vein was found attached to the hematoma between Th2 and Th3 on the left side. Histological examination of the hematoma revealed no other abnormal vessels. These findings suggested the extradural bleeding was venous in origin. The patient had a good postoperative recovery. He regained muscle strength enough to walk and urinary and fecal function within two weeks after the surgery. Sensory disturbance became minimal within a month. In the literature, MRI findings of 18 cases of spontaneous spinal extradural hematoma have been reported, including our case. According to them, hematomas within a day from onset were iso- or hyperintense on T1 weighted image and hyperintense or heterogenous on T2 weighted image. In addition, most of those between a day and a week were hyperintense on both images. In conclusion, MRI proved to be an accurate, efficient method of localizing and characterizing spinal extradural hematoma.

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Neurogenic pulmonary edema (NPE) following subarachnoid hemorrhage (SAH) usually appears immediately after the ictus and delayed onset is rare. Herein we present a case of delayed NPE following SAH due to a vertebral aneurysmal rupture. The vertebral aneurysm was clipped at 1 day after the SAH, and delayed NPE appeared 2 days later, wchich became worse and parenchymal lesion involving the entire lung. It should be noted that after SAH, NPE usually develops soon but in some cases it can develop in several days. To treat the condition, an early diagnosis must be established so that prompt therapy can be initiated. If delayed NPE is suspected, based on chest X-rays and gas analysis, then hypervolemic therapy for vasospasms should not be instituted. For cases manifesting severe NPE, therapies should include artificial ventilation with a positive end -expiratory pressure and administration of dobutamine, which were effective in our case.

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The authors report a case of a subarachnoid hemorrhage (SAH) with intracerebral hematomas and vessel occlusion from a dissecting aneurysm of the peripheral middle cerebral artery, and present details of the clinical course, and the radiographic and pathological findings. Delayed angiography, done in a few months after the hemorrhage, was particularly useful in detecting the pathology of the peripheral cerebral arteries, which did not appear in the angiograms taken immediately following the ictus.

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The authors present a case of a 29-year-old man with a colloid cyst of the thrid ventricle resected by neuroendoscope. A colloid cyst of the third ventricle is usually resected by transcranial approach or stereotaxic aspiration method. A neuroendoscopic resection of the cyst is less invasive than a transcranial resection, and yet is more reliable than a stereotaxic aspiration because one can resect the cyst with a direct view and make sure of the communication of the foramen of Monro. A neuroendoscopic resection for the colloid cyst of the third ventricle might become the first choice of surgical treatments in such lesions.

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The authors report a rare case of tuberculous meningitis that presented a granulomatous leptomeningeal thickening in the upper cranium. A 68-year-old female was admitted to our hospital because of disorientation and left hemiparesis. Gadolinium-enhanced magnetic resonance imaging (MRI) revealed an enhancement (in a thickened dura of the right hemisphere. Blood and cerebrospinal fluid examinations, and computed tomography (CT) scans yielded no specific findings. Meningeal biopsy revealed the pathohistological diagnosis of tuberculous meningitis and antituberculosis treatment was immediately started. Four months after the start of therapy, a serial MRI studies confirmed a resolution of the meningeal enhancement, and the patient was subsequently discharged without any neurological deficits. Based on our experience, a leptomeningeal biopsy is recommended for patients showing meningeal enhancement on cranial MRI.

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The authors report a rare case of a huge multicystic craniopharyngioma extending from the suprasellar region into the posterior cranial fossa. The magnetic resonance imaging (MRI) findings are discussed. Large, multilobulated cysts were found to comprise the bulk of this tumor. These cysts were aspirated and for an adjuvant therapy, bleomycin was injected into the remaining tumoral cavity. Postoperatively, the patient developed meningitis but eventually did well and was able to resume his normal daily routine that included school attendance. Risks involved in an extensive removal of a craniopharyngioma depends on two factors : the size and site of the tumor, and these factors have a direct bearing on the prognosis. The purpose of this report is to record marked extension and very unusual localization of a craniopharyngioma.

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The authors report a rare case with arteriovenous fistula (AVF) at V3 portion of the left vertebral artery with spontaneous regression. A 33-year-old woman came to our hospital complaining of a headache. She showed no neurologic abnormality but a vascular bruit was noted on her left mastoid region. Angiography revealed the AVF at the left vertebral artery emptying into the surrounding venous system. Little steal phenomenon was noted from the contralateral vertebral artery, although the filling of the basilar artery from the left vertebral artery was poor. Subsequently she was observed without any interventional treatment for 2 months until the follow-up angiography was performed, which revealed spontaneous regression of the AVF with residual arterial pouch at the orifice of the AVF.

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Resection of anterior cranial fossa tumors, traumatic head injuries, and craniotomies for other purposes can result in anterior cranial fossa floor defects. Communication between the anterior cranial fossa and nasopharynx often causes pneumocephalus, cerebrospinal fluid rhinorrhea, and intracranial infections. A variety of techniques, including pericranial flaps, galeal flaps, temporalis fascial flaps, split rib, and calvaria grafts have been used to reconstruct anterior cranial fossa floor defects. The purpose of this study was to investigate the utility of autogeneous iliac bone grafts with a galeal flap in the reconstruction of this type of cranial defect. This new technique was employed in the treatment of two patients who suffered recurrent pneumocephalus and intracranial infections secondary to anterior cranial fossa floor defects that resulted from a head injury in one patient, and aneurysm clipping operation in the other. At surgery, the cortical layer of the iliac bone graft was removed, leaving only cancerous bone. The graft was packed tightly into the anterior cranial fossa defect with cancerous bone chips. A vasculalized galeal flap was placed over the graft. Follow-up examination of the two patients at 6 and 12 months demonstrated bone integrity in the anterior fossa floor and graft viability. Neither patient suffered late complications. In summary, the iliac bone graft is ideal for the reconstruction of anterior fossa floor defects because it is possible to obtain a sufficient quantity of cancerous bone to fill the gap, it is easy to shape the graft, cancerous bone demonstrates excellent bony fusion and infection resistance, and the completed reconstruction provides a rigid bony barrier between the anterior cranial fossa and the nasopharynx.

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The authors report a rare case of transnasal penetration of the skull base from injury by a gardening prop. When a 57-year old female stambled and fell over, the prop was impaled a length of about 5 cm into her left nostril. She had a nose bleed with a severe headache just after it was pulled out. On her admission, she was clearly conscious, and there was cerebrospinal fluid (CSF) leaking from her left nostril. Plane skull X-rays showed a fracture of the sellae turcica, and a computed tomography (CT) scan showed a lot of air in the subarachnoid space and ventricles. We diagnosed CSF rinorrhea and pneumocephalus due to the perforation of the tuberculum sellae. At that time an emergency operation was performed. The operative findings showed that small bone fragments could be seen in the scarred pituitary fossa. The floor of the sellae turcica was repaired with temporal muscle and fascia. She had a good postoperative course. While the clinical signs and symptoms of a patient with a transnasal penetrating injury of the nasal cavity are occasionally not so serious, we should keep in mind the possibility of intracranial complications and perform radiologic evaluations, paticularly using CT scan and/or magnetic resonance imaging (MRI).

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A specially-designed nerve root retractor for a lumbar microdiscectomy is described. This instrument has been used successfully and has been found useful. By using this instrument, excellent exposure of the operating field as well as effective control of epidural venous bleeding is achieved during the microdiscectomy.

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