The effect of combined intravenous injections of pH4 treated acidic human normal immunoglobulin and antibiotics on severe infections was examined in 14 postoperative (4 meningitis, 7 pneumonia, 3 subcutaneous abscess) and 6 non-operative patients. One case of postoperative meningitis received the additional intrathecal immunoglobulin. In total, 19 (95%) and 15 (75%) patients improved symptomatically and microbiologically, respectively. No side effects were obsereved. This combined therapy may be valuable in both severe non-operative and postoperative infections.

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We report on biliary tract infections that were found in neurosurgical patients at our hospital. Among 829 neurosurgical patients treated by our department over the past three years, abdominal echographic findings led to the diagnosis of cholecystitis or cholangitis in 12 patients. These patients consisted of 11 males and I female, from 37 to 73 years of age (mean ; 5/~.7) . A11 12 patients presented high fevers, elevated liver values, and biliary tract infections. For therapy, antibiotics were administered, which were found to be completely or moderately effective in 11 of these 12 cases. In hospitalized neurosurgical patients, cases presenting associated cholecystitis or cholangitis are rare ; in our hospital this amounts to 1.4% of all neurosurgical cases. Therefore, the possibility of a biliary tract infection should also be taken into consideration when neurosurgical patients suddenly develop a high fever of unknown origin and/ or show abnormal blood test findings. However, the prognosis is good for neurosurgical patients who develop associated cholecystitis or cholangitis if the condition is detected early by echography and prompt antibiotic treatment is provided.

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For cranioplasties, we have previously reported on the efficacy and safety of using a mixture of hydroxyapatite granules and the tricalciumphosphate composite (Ceratite^<(R)>) with fibrin glue (Beriplast P^<(R)>) . Continuing our research further, we have now investigated the biocompatibility of cranioplasty in rats. Two sets of Wistar rat (250-300 g) underwent a small craniectomy of the parietal bone, about 4 x 5 mm in size, without causing damage to the dura mater. The Ceratite^<(R)> in the form of granules, 0.3-0.6 mm in diameter, was then applied to the bone defect with Beriplast P^<(R)>. Postoperatively, at 3 and at 12 months, the results in each rat set, consisting of 6 rats each, were respectively evaluated. To accomplish this, 10 μm-thick sections from each set were prepared and stained with hematoxylin and eosin and examined under light microscopy. Results revealed that at 3 months postoperatively, there were signs that an excellent cranioplastic repair was in progress, but newly-formed bone had not yet to be seen among the Ceratite^<(R)> granules. However, at 12 months postoperatively, the repair appeared to be progressing well, for regenerated bone was observed amongst the Ceratite^<(R)> granules. Cranioplasties using Ceratite^<(R)> granules and Beriplast P^<(R)> have been performed for 22 neurosurgical patients, including one with a posterior fossa bone defect, and neither an infection nor local abnormal granulation were noted during the postoperative follow-up. These findings suggest that composite ceramics possess an excellent biocompatibility, and that the combined usage of composite granular ceramics and fibrin glue is both useful and safe for cranioplasties.

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Profound hypothermia therapy is effective for brain ischemia. However severe complications including cardiac arythmias, severe infection, and coagulation abnormalities cause severe mortality. Recently, in animal models of head injury, mild hypothermia (cooling the brain to 32-33℃) has significantly limited tissue damage and improved functional recovery. Clinical studies of treatment with mild hypothermia have been reported, and its efficacy is recognized. the mechanisms of mild hypothermia may include reduction of cerebral metabolism, inhibition of excitatory neurotransmitter release, stabilization of cell membranes, protection of the blood brain barrier. In contrast to profound hypothermia, the frequency and severity of systemic complications are reduced significantly. We report here a good outcome in a case of severe head injury treated with mild hypothermia. A 34-year-old male was admitted following a traffic accident in a comatose state, scoring 4 on the Glasgow Coma Scale. A computed tomography scan of the head revealed a leftsided acute subdural hematoma with severe midline shift. The initial intracranial pressure (ICP) was 7O mmHg, and saturation of the jugular bulb was 36%, suggesting severe brain ischemia. Emergency surgery and barbiturate therapy were performed. Three days after the operation, ICP gradually increased to 40 mmHg, and could not be controlled with either hyperventilation or highdose barbiturate therapy. We therefor administered mild hypothermia therapy using a blanket 96 hours after injury. Tympanic temperature was controlled at 32-33℃ for 3 days, and gradually rewarmed to 37℃ for 3 days. During hypothermia ICP was controlled under 20 mmHg, and no severe systemic complication was recognized. The patient is now able to lead a normal life, although some sensory aphasia persists.

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The authors describe a case that presented an ostemoa of the frontoethmoidal sinuses that led to the formation of an intracranial mucocele. Based on the authors' experience in treating such cases and a review of the pertinent literature, the authors discuss ways to achieve a correct diagnosis and proper surgical treatment, so as to avoid excessively aggressive treatment for a benign lesion.

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Reported is a case of a non-penetrating traumatic vertebral arteriovenous fistula (AVF) that disappeared spontaneously within four months. Among traumatic vertebral AVFs, a non-penetrating type is rare. It also should be noted that a vertebral AVF can develop from a relatively slight injury such as cerebral concussion, and that the possible reason that may account for the development of AVFS due to a blunt injury is the stretching or an avulsion of the arterial branches. In a review of the literature that included this case, only 8 cases of a spontaneous disappearance of a vertebral AVF have been reported. Seven of these 8 cases involved females with no visible vertebral bone fracture. Further, more than a month elapsed before the spontaneous disappearance of all 8 AVFs. Based on the author's experience and findings, when an AVF is suspected in asymptomatic or slightly symptomatic cases, if intravascular surgery must be delayed far some reason, vertebral angiography should be performed a few months after AVF onset and the patient kept under careful clinical observation.

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We report the case of a pituitary mass that rapidly reduced after start of steroid therapy. The patient, a 25-year-old woman, had complained of headaches and visual disorders that began during the 8th month of pregnancy : the symptoms worsened soon after giving birthy. Ophthalmological examinations revealed bitemporal hemianopsia with bilateral impaired visual acuity. Further, CT and MRI revealed a symmetric pituitary mass with a suprasellar extension. Endocrinological tests disclosed hypopituitarism consisting of a low PRL, TSH, ACTH, LH, and FSH response to hormone stimulation. Immunologically, an antinuclear antibody was also detected. These findings lead to a diagnosis of lymphocytic adenohypophysitis and steroid therapy (prednisolone, 60 mg/day) was initiated. Two days after the start of therapy her visual disturbances began to improve and returned to normol 2 weeks later. CT and MRI also confirmed that the pituitary mass had markedly reduced in size 2 weeks after the start of steroid therapy. These findings suggest that steroid therapy may be effective for reducing masses associated with lymphocytic adenohypophysitis.

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The authors report the case of an arteriovenous malformation in which malignant hyperthermia (MH) occurred during surgery while the patient was under general anesthesia induced by isoflurane. Isoflurane has a protective effect against brain damage, so this anesthetic is commonly used for neurosurgical procedures. However, if MH occurs, the symptoms are fulminant and the prognosis is poor. The authors herein describe MH etiologies, symptoms, and therapies and emphasize the importance of preoperative examinations, the selection of anesthetic methods, the early detection of symptoms and the early initiation of therapy.

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We report a case of an arteriovenous malformation (AVM) that showed extravasation on cerebral angiography. The patient, a 33-year-old male, was immediately admitted to hospital because of a headache, vomiting, right hemiplegia, and a loss of consciousness. CT scans revealed a large intracranial hematoma in the left frontal lobe. Angiography taken 2- hours after he experienced this attack demonstrated an AVM. The nidus was 3 cm in diameter and the AVM, which was being fed by the middle cerebral artery, showed extravasation. Though the patient was comatose, an emergency removal of AVM was performed and the hematoma was evacuated. The patient subsequently made a good recovery. This case is discussed and previous cases in the literature are reviewed.

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We report a fatal case of a ruptured nocardial brain abscess involving the cerebral ventricle. A survey of the literature has revealed that about one third of the cases of central nervous systerri nocardlosis are of primary origin. Further, routine antibiotic therapy for an intracranial abscess is not effective for nocardiosis, and a therapy that combines sulfonamide with trimethoprim is the treatment of choice. Early diagnosis is essential. This requires identification of the causative organism. Also, a sensitivity test to ensure that the patient can be given antibiotics is necessary for management. A review of the literature indicates an extremely poor outcome for cases in which an abscess ruptures into the ventricle. Since abscesses have a tendency to rupture into the nearest ventricle, we thus emphasize the importance of early surgical treatment, even if a ventricular rupture has occurred.

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The feasibility of MR FLAIR pulse sequence was studied in two cases with monoparesis. FLAIR images supressed the CSF signal and enabled visualization of small lesions in the cerebral cortex. It thus was concluded that an advantage of this sequence method is that small lesions of the cerebral cortex or brain stem that are close to CSF can be visualized for evaluation.

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The newly developed Yasargil titanium clips for cerebral aneurysms (AESCULAP Co.) are claimed to reduce the number of artifacts on postoperative CT and MRI assessments. To confirm the merits of such clips, new Yasargil titanium aneurysm clips were clinically investigated in situ as seen on using an 1.5T MR imager. These titanium clips appeared to cause far fewer clip-induced MR and CT artifacts than did phynox and elgiloy aneurysm clips. Further, no titanium clip movement was seen after placement in the MR images. Based on these experimental findings, titanium clips were used to repair 26 cerebral aneurysms. Postoperative CTs, particularly Helical CT scannings, and MRIS Showed very few artifacts in the images of all patients. It thus has been concluded that titanium aneurysm clips are better than other types of aneurysm clips for postoperative imaging evaluations of the patient's neurological status.

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The authors describe their experience in providing an inferior vena cava filter that was inserted percutaneously to prevent a pulmonary embolism (PE) recurrence in two patients who had had a cerebral infarction and had developed deep venous thrombosis (DVT) in a paralyzed leg. Unlike standard therapy for DVT and PE cases that requires systemic anticoagulation and bed rest for more than three months, these two patients soon received physiotherapy and mobilization after this procedure. The indications for this new PE therapy for neurosurgical patients are discussed.

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