Anterior cervical fixation with screw-plate is becoming popular in the management of cervical instability. The Caspar and Synthes (locking plate, Morscher plate) plating systems are currently used most extensively for this purpose. We experienced 22 patients of cervical trauma, cervical spondylosis, and OPLL who underwent anterior decompression, interbody fusion, and anterior fixation with these plating systems. Of 22 patients, seven patients were fixed with the Caspar, and other 15 patients with the Synthes plating system. All patients fused or stabilized with minimun follow-up period of one year without neurological deterioration. There was no serious complication relating to the hardwares. Asymptomatic breakage of the Caspar screw occurred in one patient after the completion of bone fusion. Our favorable result and previous reports indicate that anterior plating with interbody fusion may provide reliable stabilization of the cervical spine in a safe and effective manner. In reviewing the literature, the shape and material, operative procedures, biomechanical characteristics, results and complications of these two plating systems are discussed.

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Conventional cerebral angiography is essential for achieving the diagnosis of Moyamoya disease. It is, however, an invasive examination, especially for the pediatric patients. In this paper, we report on the results of an investigation as to whether MRA is able to accurately visualize the steno-occlusive changes in the carotid fork and the basal moyamoya vessels less invasively. Twenty patients among them 16 children, who were diagnosed as having Moyamoya disease with conventional angiography underwent MRI and MRA using a 1.5T MR unit (Signa, G. E.). Angiographically, 37 sides were determined to be in stage 3. MRA was performed using two-dimentional time-of-flight (2D-TOF), 3D-TOF, and gadolinium (Gd)-enhanced 3D-TOF methods. The 3D-TOF MRAS showed almost equal sensitivity to that of conventional angiography for the detection of steno-occlusive changes in the carotid fork. However, it was difficult to visualize the moyamoya vessels clearly. Further, 3D-TOF, 2D-TOF, and Gd-enhanced 3D-TOF methods depicted the moyamoya vessels in 65%, 79%, and 80% of the examined sides, respectively. In contrast, MRI visualized the moyamoya vessels as multiple flow voids in the basal ganglia in 38 of 40 sides (95%o)' Based on the above findings, it thus was concluded that approximately 90% of the stage 3 Moyamoya disease cases could be diagnosed by a combination of 3D-TOF MRA and MRI without the use of conventional angiography.

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We have compared the results of a vertebral artery dissection in 10 patients divided into two groups : 7 patients who only presented a subarachnoid hemorrhage (SAH), the SAH-only group, and 3 patients who presented not only an SAH but also an infarction, the SAH and infarction group. In 2 of the 3 patients in this latter group, the cerebellar infarction had occurred at the time of SAH, and the remaining patient fell into a coma due to a brain stem infarction 72 hours after the SAH attack. In 6 patients of the SAH-only group, vertebral angiography showed typical signs of a dissecting aneurysm of the vertebral artery (aneurysmal dilatation and the pearl and string sign). Cupping of the bleeding point of the aneurysm combined with proximal clipping of the acute-stage vertebral artery was successfully accomplished in one patient. The remaining 4 patients of this group were chronic stage patients who received a proximal clipping of the vertebral artery or trapping of the aneurysm of the 7 patients in this group, all who underwent direct surgery had favorable outcomes. With regard to the SAH and infarction group, diagnosing the dissection of the vertebral artery was not easy because angiography only revealed the presence of a stenotic lesion of the vertebral artery but no signs that were typical of a dissecting aneurysm. Of the 3 patients in this group magnetic resonance imaging (MRI) showed a tiny mural hematoma of the right vertebral artery in one patient. Further, 2 acute-stage patients died. As for the remaining chronic-stage patient, proximal clipping of the vertebral artery was performed but we were unable to determine the correct bleeding point. This patient, a female, had shown a good postoperative course until she died from an acute subdural hematoma and complications resulting from a lumbo-peritoneal shunt for her hydrocephalus. As it is difficult to determine the correct bleeding point in such cases, selecting the proper therapeutic strategy for patients presenting an arterial dissection of the vertebro-basilar artery and an SAH and an infarction is not easy.

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We have analyzed the clinical features and outcomes of nontraumatic intracranial hemorrhage in 9 patients with liver cirrhosis. The results have revealed that the hepatitis C virus was the most frequent cause of their liver cirrhosis. Further, the major site of intracranial hemorrhage was found to be the subcortical region of the cerebrum. Bleeding tendency in liver cirrhosis patients is usually due to thrombocytopenia and to reduced coagulation factors, and in all 9 patients of this study, thrombocytopenia was seen. Two of these patients also showed a prolonged prothrombin time. Five of these 9 patients underwent surgical treatment, and though bleeding complications occurred after two craniotomies, three burr-hole operations were accomplished successfully. For these patients, therapy consisted of minimaly invasive surgery with sufficient supplements of thrombocytes and coagulation factors. Three chronic-phase patients died of hepatic failure or a ruptured esophageal varix. When treating intra-cranial hemorrhage in liver cirrhosis patients, neurosurgeons should collaborate with specialists of bleeding management and the liver.

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A case involving the total removal of a clival chordoma by a Le Fort I maxillotomy is presented. The patient, a 17-year-old male, was admitted to hospital because of left tinnitus. Subsequent physiological and neurological examinations revealed the congenital obliteration of the bilateral external auditory canals, and the bilateral conductive hearing disturbance. CT scans showed a low-density tumor with no enhancement of the dorsal part of the clivus, which was partially destroyed. MR imagings also revealed the tumor as being in the dorsal part of the clivus, with the margin of the tumor becoming slightly more visible on Gd enhancement. Surgery consisted of using a Le Fort I maxillotomy and the tumor was removed totally. Postoperatively, the tumor was diagnosed as being a clival chordoma that had developed in the extradural space. MR imaging showed no residual tumor and the patient was discharged in good condition with no complications. The surgical approach for treating clival lesions by using a Le Fort I maxillotomy is briefly discussed. This approach provides a wider operative field, less retraction of the brain, and prevention of postoperative malocclusion.

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We herein report the case of a meningioma that metastasized to the scalp of a 46-year-old female. She was admitted to hospital complaining of a calvarial mass that gradually enlarged over a period of 3 years. On examination, skull rentogenogram revealed marked midline hyperostosis of the bilateral parietal bones. Further, computed tomographic (CT) scanning and magnetic resonance (MR) imaging visualized an extraaxial mass in the midparietal region that showed homogeneous enhancement on administration of contrast materials. Cerebral angiography also showed evidence of a tumor of the intra- and extracranial vertex which was being fed by the left middle meningeal and bilateral superficial temporal arteries, but the superior sagittal sinus (SSS) adjacent to the tumor showed no opacification. Based on a diagnosis of a parasagittal or falx meningioma, the patient thus underwent surgery. Intraoperative inspection revealed the presence of a tumor in the subgaleal region and in the subdural space. Further, the parietal bone was hyperostotic and it had a smooth surface. There were no other invasive findings. Thus, the tumor (Simpson, Grade III) was totally removed. A histological examination of tumor specimens led to the diagnosis of a meningotheliomatous meningioma. As no tumor cells were found in the hyperostotic bones, our conclusion was that the subgaleal meningioma was a metastatic type that had spread through an emissary vein due to an SSS thrombosis and increased intracranial pressure.

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A brain metastasis that occurs more than 10 years after a nephrectomy is rare, and we report herein a case of a cerebral metastasis from a renal cell carcinoma (RCC) 23 years after a nephrectomy. Twenty-three years earlier, the patient had undergone a right nephrectomy due to a renal tumor. Subsequently, lung cancer was diagnosed 17 years after this nephrectomy and a metastatic tumor sited in the left occipital area was extirpated. The histopathological diagnosis was an RCC. In later medical exams, no evidence of recurrence at the prior operative site was noted and the left kidney was normal. This time on hospital admission, a metastatic lung cancer was diagnosed. Although the histological origin of this metastasis was unknown, it may have developed from the RCC. This case appears to indicate that after a long latent period the metastatic route was the transpulmonary pathway via the pulmonary arterial circulation. When deciding on whether surgery should be performed for such cases, the overall preoperative status of the patient should be taken into consideration.

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Described is the case of a 22-year-old man who was admitted to hospital in an unconsciousness state and manifested bulbar palsy and abnormal ocular movements as a result of severe head and neck injuries that he had sustained 5 months earlier. Magnetic resonance imaging (MRI) revealed a pontine infarction and cerebral angiography demonstrated occlusions of the left common carotid artery, the left vertebral artery and the basilar artery. This case exemplifies the possibility that delayed intracranial arterial occlusions can occur even several months after a head and neck injury.

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Tracheo-innominate artery fistula is a fatal complication which can occur after a tracheostomy. We success fully treated a 21-year-old female case. She had been operated on for a bleeding cavernous angioma in her brain stem. Fourteen months after undergoing a tracheostomy, she suffered a sudden massive hemorrhage at the site of her tracheostomy. The hemorrhage was controlled by the hyperinflation of the endotracheal tube cuff. A median sternostomy was then carried out and the trachea and innominate artery were repaired, however nine days later rebleeding ocurred. At the operation, a right axillofemoral bypass was done with a Hemashield^lt;(R)>. The patient recovered without any complications. For the prevention of tracheo-innominate artery fistula, we concluded as follows : 1) A tracheostomy should not be done at the lower level of the fourth tracheal ring. 2) Infection around the tracheostomy should be prevented. 3) All tube movement should be avoided to prevent any motion-induced pressure necrosis. 4) The pressure of endotracheal tube cuff should be correctly maintained from 15 to 25 mmHg.

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Described is the case of a 79-year-old woman with multiple myeloma who presented a subcutaneous mass in the mid-parietal region. The mass was not painful, but from 3 months prior to admission to hospital, it had gradually increased in size. Her laboratory data revealed mild anemia and elevation of her serum kappa-type immunoglobulin A (IgA). Bone marrow aspiration samples taken by sternal puncture yielded normal findings. Plain craniograms showed a large bone defect corresponding to the site of the subcutaneous mass and a small"punched-out lesion"in the right parietal bone. Further, computed tomographic scans showed an extradural enhanced mass that completely involved the calvarium. Arteriography revealed that this tumor was being fed by the superficial temporal and occipital arteries but with no supply from the internal carotid branches. Also, displacement of the superior sagittal sinus was noted. The patient surgically underwent a total removal of the mass including the surrounding bone, and the pathological findings of examined specimens revealed the tumor to be a typical plasmacytoma with an immuno-reactivity for IgA and kappa light chain antibodies. Postoperatively, she received chemotherapy consisting of predonisolone and melphalan and, at one year postoperatively, is still alive. A large plasmacytoma of the head is rarely encountered in patients with multiple myeloma and only 30 such cases have been reported in the literature. These lesions have the propensity of shortening the survival time of multiple myeloma patients, especially if neurological signs are presented. In such patients, a cerebral insult, due to such causes as a herniation or a meningeal involvement, is thought to be the main cause of acute death. Plasmacytomas Involving the cranium, particularly those located extradurally that show no invasion to the cerebral parenchyma, can be easily resected with an acceptable amount of risk and it has been reported that such surgery prolongs the survival time. It is thus felt that a surgical excision may prove useful for some patients having an intracerebral single lesion or an extradural plasmacytoma of the skull base, taking into consideration their overall preoperative condition and the recent advances made in microsurgical techniques.

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We report the case of an glioma that was initially suspected of being a cavernous angioma. The patient, a 19-year-old male, had a recurrence of focal tonic seizures of the left upper limb that he had the first experience at age 16. Initial CTs at that time revealed a small calcified lesion under the central sulcus of the right hemisphere. However, because he showed no neurological deficits, conservative treatment was initiated, consisting of only anticonvulsants. On re-examination, now that these focal seizures had returned, CTs revealed that the calcified lesion had enlarged. Therefore, γ-knife radiosurgery was provided to be eliminate this lesion that was found to a glioma. Three months postoperatively, however, the focal seizures recurred and CTs demonstrated extensive perifocal edema of a lesion in the right cerebral hemisphere that appeared to account for his aggravated left hemiparesis. Thus, this tumor was subtotally removed by a craniotomy, and a histological examination of a specimen from this tumor led to the diagnosis of an astrocytoma. When using γ-knife radiosurgery to remove tumors, extensive cerebral edema can occassionally occur. This may be due to excessive postoperative high-dose radiation. Therefore, great thought must be given to the postoperative consequences before using γ-knife radiosurgery for tumoral treatment.

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The efficacy of surgical treatment of intracranial aneurysms and arteriovenous malformations (AVM) is dependent on complete obliteration of the lesion, without compromise of normal cerebral vessels. It is desireble to confirm the completeness and precision of the surgical result in the operating room before the wound is closed. Recently portable digital subtraction unit and radiolucent skull clamp are employed for intraoperative angiography. However, these equipments are still expensive, so they are not always available in every operating room. For these reasons we designed a new headholder with cassette (Angio-Head Holder) for intraoperative angiography, by which angiogram is easily obtained using conventional portable X-ray apparatus. The cassette is fixed with a clamp between the head and the U-shaped headholder, which produces a clear image. Since the cassette holder is movable with a fixing device, we are able to select various views and obtain subtracted images in the nearly same size as lesions. If intraoperative angiogram demonstrate residual AVM nidus or incomplete clipping of aneurysm, subsequently we are able to continue surgical procedure precisely.

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The authors describe a case of a 49-year-old male who was admitted to hospital because of a gait disturbance. Magnetic resonance imaging (MRI) revealed a large tumor that extended from the suprasellar region to the foramen magnum. Thus, a two-stage operation was performed to remove this lesion. Based on the results of a pathological examination of a resected specimen, the tumor proved to be craniopharyngioma. Only six cases of a craniopharyngioma of the posterior fossa have been reported in the literature, and tumors at this unusual site are characterized by a cystic formation and are usually found in younger subjects. Further, the endocrinological pituitary functions show values that are usually within normal range. With regard to the surgery provided, a transcondylar approach and an orbitocraniobasal approach proved very useful and offerred a satisfactory microsurgical view for excision of the tumor, which was sited ventral to the brain stem and suprasellar region.

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