we carried out carotid occlusion tests with regional cerebral blood flow (rCBF) study using H_2^15O positron emission tomography (PET) for 7 cases of unruptured large internal carotid artery (ICA) aneurysms and I case of carotid stenosis. RCBF was measured with PET under Matas maneuver in 4 patients and under balloon occlusion test (BOT) in 4 patients. In the cases with Matas maneuver, we also performed conventional BOT to evaluate carotid stump pressure. H_2^15O PET scan is an ideal examination for the rCBF study during an occlusion test for its excellent ability of absolute quantitative analysis and a brief scanning time. Measurement of rCBF with Matas maneuver is relatively simple and provides almost accurate information about a tolerance of a temporary or permanent occlusion of ICA, though it misgives us a possibility of an incomplete occlusion, the possibility of blood supply from the branches of external carotid artery and the shortness of the occlusion time compared to a BOT. On the contrary, measurement of rCBF with BOT enables the occlusion to be complete and enough long, while the examination becomes complicated and lengthy. It seems that we should select more accurate BOT with PET despite its complexity to detect the difficult cases that manifest intolerance on the permanent carotid occlusion and show false-negative on conventional occlusion tests.

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Presented are the results of immunotherapy using the human monoclonal antibody (CLN-IgG) for 10 cases of gliomas (6 recurrent cases, I stable case, and 3 progressive cases) . The CLN-IgG was produced by fusing UC729 -6, the human lymphoblastoid B-cell line, with lymphocytes obtained from a patient with adenocarcinoma of cervix. After a 1 mg intravenous injection of this immunotherapy on a twice weekly basis, a case of a malignant astrocytoma showed total regression, 3 cases (a case of a glioblastoma multiforme and a cases of an astrocytoma) showed a reduction in the tumoral size, and an improvement in the neurological symptoms and overall status, and another case of a glioblastoma multiforme, which had progressed rapidly and presented deteriorating neurological symptoms and an overall decline, was stabilized by continuous intravenous injection of CLN-IgG for 15 months until this patient died of pneumonia. As for the remaning 5 cases, this treatment was not effective and all 5 patients died from the progression of their tumor, 2 dying before completion of 24 weeks of therapy, 2 dying after completion of this therapy and 1 dying after this treatment was found ineffective and was replaced by other chemotherapy. During the administration of this CLN-IgG therapy, no side effects were noted nor were any abnormalities due to this therapy detected.

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Eleven operated cases of superior wall aneurysm (SWA) of the internal carotid artery (ICA) have been analyzed, especially in terms of intraoperative observations of aneurysm shape, surrounding structures and clipping -technique. Nine of the aneurysms had ruptured and two were unruptured. Three of the eight aneurysms with a thin-walled neck and a thin-walled fundus were "blister-like aneurysm". In all seven cases of the superomedial type, the aneurysm was adherent to the optic nerve, and in one of these cases it was also adherent to the frontal lobe. Among the three cases of the superolateral type, two were attached to the temporal lobe. In the single case of the superior type the aneurysm was adherent to the optic nerve. In four of the cases of SWA, the adhesions to the temporal lobe and the optic nerve were dissected successfully and a clip was applied to the aneurysm parallel to the ICA. In six cases the optic nerve adhesion could not be dissected and a clip was applied to the aneurysm across the ICA in a right-angled or oblique-angled fashion. In one case another aneurysm was located near the SWA, and right-angled cross-clipping was carried out. All eleven SWAs were successfully clipped without intraoperative premature rupture. Adhesions of aneurysmal dome to the temporal and frontal lobes can be dissected easily, but adhesion to the optic nerve are difficult to dissect. Exposure of the cervical ICA, removal of the anterior clinoid process, and intraoperative hypotension are necessary to perform dissection safely. The ideal operative method is clipping parallel to the ICA with a J-shaped dip or a curved clip. Clips are successfully applied to SWAs by adjusting the depth and angle of clipping. There are two methods of parallel clipping, which differ according to the positioning of the clip-head (spring portion) in relation to the SWA : head-proximal parallel clipping, and head-distal parallel clipping. The mothod should be chosen according to the aneurysm's shape, surrounding structures, and the number of aneurysms. Care should also be taken in postioning the clip-head so that it is not compressed after brain retraction is released. Oblique-angled cross-clipping is useful, when optic nerve adhesions are too firm to be dissected.

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This report describes a case of malignant schwannoma in the left jugular foramen and the left trigeminal nerve. A 55-year-old man complaining of headache and nausea was referred to our hospital. Neurological examina-tion revealed disturbance of left 5th, 6th, 7th, 8th, 9th and 10th cranial nerves and left cerebellar ataxia. T1-weighted magnetic resonance imaging showed a round tumor with low signal intensity in the jugular foramen and a small mass in the left trigeminal nerve. The tumors were subtotally removed, using a left suboccipital approach. Four months after the operation, spinal dissemination of the tumor cells was found. He died five months after the onset of symptoms. Microscopically, the tumor was formed by bundle of cells with elongated nuclei, scattered whorl formation, focal mitotic figures and necrosis. Some cells were strongly labeled with antibodies for glial fibrillary acidic protein and metallothionein. The histopathological diagnosis was malignant schwnnoma. The immunoreactivity for metallothionein might indicate the malignancy.

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A case of cranial fasciitis of childhood (Lauer and Enzinger, 1980) is reported. The patient, a 7-month-old girl, developed a smal1 skull tumor in her right temporal region that rapidly enlarged during the next two months. On inspection, the lesion was a rubber-hard, immobile, nontender tumor. 2 cm indiameter, sited on her right squamous suture, and the scalp covering this lesion was normal. A skull X-P revealed the tumor to be an osteolytic lesion, 1.6 cm in diameter. with a sclerotic rim. Further, computed tomographic scans showed that the lesion, which contained bone-dense material, had destroyed both the inner and outer table of the skull. Thus, Surgery was indicated. On Surgery, the mass was found to have arisen from the periosteum of the skull and appeared to have invaded the skull up to dura mater. The lesion was milky-white and showed a tendency to bleed. The lesion was extirpated with the surrounding bone, and a pathological examination of a specimen revealed a dense proliferation of fibroblastic spindle cells with a background consisting of a rich myxomatous substance in background. A spindle cell proliferation with a fascicular and storiform arrangement was also noted. Mitosis was not seen, although the nuclei of these cells were slightly atypical. Among these spindle cells, inflammatory lymphocytes were detected. Immunostaining confirmed that these cell were positive for vimentin and smooth muscle actin but negative for desmin. the epithelial membrane antigen, and cytokeratin. No recurrence of this tumor has been detected at one year of follow-up.

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we report a case of a vertebral arteriovenous fistula (AVF) associated with a duplicate origin of the vertebral artery (VA) in a 65-year-old man with C6-T1 radiculopathy. Three years earlier, he had undergone endovascular surgery for a carotid-cavernous fistula caused by the rupture of an intracavernous aneurysm, and on that occasion, the left common caroid artery had been punctured. Digital subtraction angiography revealed a duplicate origin of the left VA and fistulous communication between the left VA of proximal origin and the vertebral vein. The patient was treated by endovascular emboliza-tion with platinum microcoils. Postembolization angiograms showed complete obliteration of the fistula. A duplicate origin of the VA is rarely encountered and only 9 such cases are reported in the literature. Our case is the first report of an AVF associated with a duplicate origin of the VA. Although it is impossible to determine whether the vertebral AVF in our case was congenital or iatrogenic, the possibility of a vertebral AVF should be taken into consideration after a puncture of the neck at the endovascular treatment or after a penetrating neck injury.

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We report a case of multiple intracranial aneurysms associated with neurofibromatosis (NF) in a 30-year-old man. On seeking medical advice, the man presented a disseminated, cutaneous NF and complained of severe headache and vomiting. His blood pressure was 170/100 mmHg, but his cardiovascular system was otherwise found to be normal. Computed tomography revealed diffuse subarachnoid hemorrhage, and selective internal carotid angiography identified two separate aneurysms at the bifurcation of the right middle cerebral artery and at the anterior communicating artery. For treatment, an orbito-cranial craniotomy was performed, and a ruptured anterior communicating artery aneurysm and an unruptured middle cerebral artery aneurysm were successfully clipped. However on the 13th postoperative day, the patient suddenly lost consciousness and right carotid angiography revealed diffuse vasospasms affecting the C2 portion of the internal carotid artery, the middle cerebral artery, and the anterior cerebral artery. At 7 weeks postoperatively, the patient who developed severe left hemiparesis was discharged. Although 21 cases of a cerebral aneurysm associated with NF have been reported in the literature, a rupture of an aneurysm associated with NF is extremely rare and the prognosis is very poor. The authors stress the necessity of screening such cases with three-dimensional CT or MR angiography so as to achieve an early diagnosis, and elective repair of unruptured aneurysms in patients with NF.

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two cases of mixed/transitional pineal parenchymal tumor (PPT) were reported and special atention was paid for different clinicopathological courses of both cases. Case l, 1-year-3-months-old male, was admitted to our hospital with complaint of vomiting and gait disturbance. CT scan and MR imaging disclosed a calcified large pineal tumor associated with numerous dis-seminated regions and acute obstructive hydrocephalic condition. After emergency ventriculo-peritoneal shunt operation, seven courses of intensive/high dose chemotherapy with peripheral blood stem cell transfusion (PBSCT : 1 course=CBDCA 400mg/m^2x3days+VP-16 300 mg/m^2x4 days) were performed. Twelve months after the onset, almost disseminated regions were disappeared and main pineal region tumor was decreased. Thereafter, partial removal of tumor via occipital transtentorial approach (OTA) was done. Histological examina-tion revealed both pineocytomatous and pineoblastomatous component. Immunohistochemical examination revealed that tumor cells of both components were positive for synaptophysin and NSE, although tumor cells in pineocytomatous area showed more prominent neurogenic character than those of pineoblastomatous area. Case 2, 18-year-old male, was admitted to our hospital with complaint of intermittent headache. CT scan and MR imaging disclose a homogeneously enhanced small round tumor in the pineal region and obstructive hydroce-phalus. Partial removal of tumor via OTA and following radiation and chemotherapy (1 course=PE therapy : CDDP 20 mg/m^2 x 5 days+ Vp-16 60 mg/m^2 x 5 days) was performed successfully. Histologically, the predominant area of the tumor was high cellularity with poor cytoplasm. However, there were no mitotic figures and no lobular architecture. These histological findings were consistent with a transitional type of pineal parenchymal tumor. Our cases suggest that mixed PPT and transitional PPT have different prognosis. That is, prognosis of mixed PPT was restricted by malignant, pineoblastic component likely as Case l. On the other hand, transitional PPT have better prognosis because of its intermediate tumor cell malignancy likely as Case 2.

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We report a case of 57-year-old man with a ventral midbrain, cavernous angioma, which was successfully removed surgically by using a pterional approach. On seeking medical helps, the patient complained of retroorbital pain and diplopia. A subsequent MRI revealed a ventral, midbrain, cavernous angioma. Surgery was indicated and a subtotal removal of the angioma was then performed using a subtemporal approach. Three years later, the patient again experienced headache and diplopia, and developed left hemiparesis. A neurological examination identified Weber's syndrome and MRI revealed a recurred cavernous angioma with a hematoma. Thus, a total surgical removal of the angioma was then successfully performed by using a pterional approach. Based on this experience, we have concluded that a ventral, midbrain, cavernous angioma can be effectively removed surgically by using a pterional approach.

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Chronic subdural hematoma associated with advanced cancer poses a management dilemma for neurosurgeons because of its exclusively poor prognosis and coagulopathy. A 55-year-old woman with coagulopathy due to advanced cancer was successfully treated by emergency percutaneous subdural tapping for chronic subdural hematoma presenting transtentorial herniation. The usefulness of this procedure, which is less invasive than conventional burr-hole craniostomy, for patients with coagulopa-thy and advanced cancer is discussed.

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We report a case of syringomyelia in which the size of the syrinx reexpanded following foramen magnum decompression. The patient, a 15-year-old male, was admitted to our hospital because of numbness and spontaneous pain of the left upper limb. Since MRI revealed Chiari type I malformation and syringomyelia, we performed C1 laminectomy and foramen magnum decompression that only opened the external dural layer. Three days postoperatively, his neurological findings improved, and the syrinx had reduced in size. However, at 3 months postoperatively, numbness in his left upper limb recurred and the syrinx reexpanded. We carefully monitored his neurological symptoms and, at 5 months postoperatively, the syrinx once again reduced in size. Previously, no report has indicated that the size of the syrinx can change after foramen magnum decompres-sion, and the mechanism that causes this is unknown. However, it should be kept in mind that the size of syrinx can fluctuate after foramen magnum decompression.

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The authors report on new microscissors that they recently devised that incorporates and additional joint between the tip and the grip that enables the microscissors to bend vertically, the angle of this bend depending on the needs of the user. The advantage of these microscissors over straight, conventional microscissors is that they can be inserted into very narrow spaces and, by easy manipulation, reach tiny internal body areas requiring scissoring. Thus, when applied to cerebral repairs, there is little or no damage to the cerebral tissue. Further, the force involved in retracting these microscissors is lessened, since this unique bending capability enables better maneuverability for a smoother withdrawal. These microscissors have been successfully used to repair over 5 cases that have included the dissection of a sylvian fissure for an aneurysmal clipping, treating an arteriovenous malformation and a cerebellopontine angle tumor. In all instances there were no complications.

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