Internal carotid-ophthalmic (IC-oph) aneurysms account for 1.5-8.0% of all intracranial aneurysms. They are difficult to treat by direct surgery, and the surgical results are poor compared with those for other types of aneurysm. We report on the treatment of 4 patients with IC-oph aneurysmS using Interlocking detachable coils (IDO and immediately detachable coils (IEDO via an endovascular approach. The patients were 2 men and ?_ women who ranged in age from 44 to 55 years. The aneurysms were small in 3 patients and large in 1. Immediately after embolization, 90-100% obliteration of the aneurysms was achieved in all patients. In the patient with a large aneurysm, more than 90% obliteration was achieved. Follow-up angiography 13 days to 6 months after emboliza-tion showed no coil compaction. There were no complications during or after the procedure. Clinical follow-up findings indicated good recovery in all patients.

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After magnetic resonance imaging to confirm tumor location, 7 jugular foramen neurinomas (JFNS) were classified into the intradural type ( 3 ) and intra/extradural type ( 4 ). The intradural type shows no extradural extension through the jugular foramen and is localized in the posterior fossa. The intra/extradural type extends both intradurally into the posterior fossa and extradurally into the skull and neck. The symptoms, surgical treatment, and results in these 2 types of JFN are described. The initial symptom in patients with intradural-type neurinomas is hearing loss, without palsy of the 9th, 10th, and 1lth cranial nerves. The diagnosis is often delayed, and thus large tumors in the posterior fossa are commonly associated with hydrocephalus. Tumor removal via the lateral suboccipital retrosigmoid approach can partially or completely restore hearlng. Although hoarseness and difficulties in swallowing may occur transiently after surgery, postoperative function of the 9th, 10th, and 1lth cranial nerves is good. Patients with the intra/extradural type of neurinoma generally present with palsy of the 9th, 10th, and 1lth cranial nerves. These tumors can be completely removed via lateral suboccipital craniotomy combined with either the transjugular or infratympanlc approach. Howvever, postoperatively the functioning of the 9th, 10th, and 1lth cranial nerves is poor. It is useful to classify JFNS Into the intradural and intra/extradural types based on tumor location since they have different cllnical characteristics.

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The present study was undertaken to determine the surgical indications, operative techniques, and postoper-ative management in patients over the age of 80 years with cerebi-al aneurysms. Fifteen such patients were analyzed, 3 with symptomatic unruptured aneurysms and 12 with ruptured aneurysms. The clinical grading scale of Hunt and Kosnik was correlated with outcome. The rate of recovery for skills of daily living was 100% (3 of 3) In patients with grade O, 80% (4 of 5) in patients with grade I and la, 50% (2 of 4) in patients with grade II, and O% (O of 3) in patients with grade 111 aneurysms. General complications resulting from disturbance of consciousness were responsible for the unfavorable outcomes. We think that direct surgery is the treatment of choice in elderly patients with grade O symptomatic aneurysms, I, Ia, and II. In those with grade 111 aneurysms, however, Sru~gery should be postponed until consciousness is recovered.

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Hellcal or spllal computed tomoglaph) (CT) scannlng allows contlnuous clata the acqulred rapidly, and when a correctly timed intravenous injection of contrast material is administered, helical CT angiography can be performed. To determine the utility of helical CT angiography in the evaluatioll of carotid artery stenoses, helical CT images (reconstructed three-dimensional images, reconstructed multiplanar images, and two-dimensional axial images) obtained from 60 patients (120 carotid bifurcations) were compared with images obtained using conven-tional angiography. Based on conventional angiographic criteria, 2'2 arteries had no stenosis, 26 had mild (less than 50%) stenosis, 69 had severe (more than 50%) stenosis, and 3 were occluded. A11 carotid bifurcations were clearly identified on helical CT scanning and there were no complications. There were no motion artifacts due to the short examination time. In normal arteries, reconstructed three-dimensional images provided accurate anatomic depiction of the carotid bifru~cation. Calcification was present at the stenotic lesion in 52 arteries (4 of 26 arteries with mild and 48 of 69 with severe stenosis) . In 43 arteries in which the stenotic lesion was free of calcification, the degree of carotid stenosis determined using reconstructed three-dimensional images correlated with that determined using conventional angiography. In 19 of 52 arteries with calcification at the stenotic lesion, the calcification was focal and did not obscure the vessel lumen signiflcantly when viewed from multiple angles. In the other 33 arteries, the calcification was dense and/or circumferential, making it difficult to evaluate the axial images alloLved evaluation of the vessel lumen in the area of calcification, and the clegree of stenosls was similar to that determined by conventional angiography. In 3 arteries, occlusion of the internal caroticl artery was seen in reconstructed three-dimensional images and was confirmed by conventional angiography. In conclusion, helical CT is a useful and safe technique for evaluating the carotid artery bifurcation, and severity of stenosis can be judged accurately on helical CT images including reconstructed three-dimensional, multiplanar reconstructive, and two-dimensional axial images.

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A case of transient global amnesia (TCA) following cerebral angiography is described. A 58-year-old woman was admitted to our institution to examine a small subcortical infarction in the right parietal lobe. Digital subtraction angiography (DSA) was performed with a 5 French catheter via the right transfemoral approach. No sedatives were administered during the procedure. Examination of selected internal carotid arteries yielded normal results, except for a filling defect noted in the right parietal region. The catheter was canulated directly over the tortuous portion at the origln of the left vertebral artery. Anteroposterior and lateral anglographic views were obtained with a total volume of contrast medium (Iopamidol 300) of 8 ml, when the left posterior cerebral artery was occluded dlstal to the bifurcation of the calcarine artery and the catheter was immediately wlthdrawn. The patient became disoriented and asl{ed where she was and why she was in a hospital. However, she remained alert, and no aphasia or apraxia was noted. Although remote memory was intact, she was unable to remember anything after the time of admission. One hour later ^<99>mTC-HMPAO single-photom emission computed tomography showed left-sided medial temporal hypoperfusion. On the subsequent day, electroencephalography revealed sporadic slow waves predominatlng in the left temporal region. MR imaging and CT scans did not change from the initial findings. The patient's amnesia resolved rapidly 2 hours after onset, but loss of memory concerning the anglographic procedure persisted. Repeat angiography 4 weeks later confirmed recanalization of the previous occlusion. TGA following cerebral angiography is a well-known entity, and is assumed to be due to embolus formation associated with catheter manipulation or neurotoxicity resulting from the contrast medium. The possible mecha-nism of TGA in our patient is discussed, emphasizing not only the role of the instruments used but also the significance of decisions made by experienced operators in reducing the complications associated with angiogra-phy.

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Both a 54-year-old man and a 61-year-old woman, who possessing ventriculo-peritoneal shunt (V-P shunt) after hydrocephalus due to ruptured aneurysm showed brain herniation sign after traumatlc acute subdural hematoma, but they recovered pretraumatic state after treatment. Ill case of the traumatic acute subdural hematoma with V-P shunt, which may play a role in accelerating for increasing of hematoma by decompression effect, in spite of lllinor head trauma. But if an emergency operation was performed, the patient was well survived.

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A case of a ruptured anterior communicating artery (AComA) aneurysm with an anomalous right infraoptic course of the anterior cerebral artery (ACA) is reported. A 56-year-old woman was admitted to our hospital wlth complaints of headaches and consciousness disorder. Computed tomography (CT) revealed thick subarachnold hemorrhage in the basal cistern and bilateral Sylvlan fissures. Four-vessel angiography showed a saccular aneurysm at the anterior communicating artery (AcomA), and an anomalous vessel which arose from the right C2 portion and running medially and superiorly. The anomalous vessel terminated in the region of the AcomA and supplied the bilateral pericallosal arteries. The left A1 segment was not shown on angiography. Surgery was performed on the first day of admission by the anterior interhemispheric approach. Surgery confirmed that the anomalous branch of the right ICA ran beneath the right optic nerve, ascended between the optic nerves, and supplied the AcomA system. The left hypoplastic A1 segment. which entered the AcomA, was seen during operation. There are only 40 reported cases of this anomalous artery including the present case. Twenty two aneurysms were involved in 20 cases, and the frequent site of the aneurysms (15 cases) was in the anterior communicating artery. There have been various explanations for the etiology of this anomalous ACA. We revievved this anomaly and discussed it from an embryological point of view.

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The authors report on a patient in whom a colloid cyst located in the anterior third ventricle was treated with stereotactic steerable endoscopic surgery. By inserting the steerable endoscope in the right frontal lobe, the membrane of the capsule was punctured, allowing maximum aspiration of whitish zoll exudate. Although an immediate postoperative CT scan showed a cyst content of 40%o, CT scans performed 7 days and 7 months after surgery indicated that the cyst had completely disappeared. Therefore, the steerable endoscopic extirpation of colloid cysts within the third ventricle is a useful technique that is less invasive than other types of surgery.

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We report on a patient with a brain metastasis from an alveolar soft part sarcoma of the leg who recovered after tumor removal followed by induction of hypothermia. A 29-year-old woman had undergone surgery to remove an alveolar soft part sarcoma of the left leg 3 years previously, and to remove a metastatic tumor of the lung 2 months prior to admission to our institution with a diagnosis of metastatic brain tumor. She was initially treated with stereotactic radiosurgery, but the day after radlosurgery became comatose due to aggravated edema of the brain. After administering barbiturate therapy, we totally extirpated the brain tumor. However, marked intracranial hypertension continued postoperatively, and we induced hypothermia to control the intracranial pressure. While the patient remained in a hypothermic state the intracranial pressure was well controlled and brain CT scans showed decreased edema. After rewarming, the patient was discharged without any neurological deficits except for visual acuity lost; in the left eye. Hypothermia is believed to protect against brain damage, and our results suggest that it is also effective in reducing the vasogenic edema associated with bi-ain tumors. Because alveolar soft part sarcomas grow slowly, surgery appears to be the treatment of choice.

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Malignant lymphomas occurring in the area of the cavernous sinus are occasionally difficult to differentiate from pseudolymphomas. We report on a 54-year-old man who presented to our institution with the chief complaint of diplopia. Neuroradiological studies revealed a mass in the bilateral cavernOus sinuses as well as in the right anterior middle cranial fossa. Operative findings showed that the tumor extended to the skull base of the middle cranial fossa and penetrated the dura mater. Immunohistochemical studies were unable to determine whether this was a "true" Iymphoma or an inflammatory lesion. Gene analysis for immunoglobulin heavy chain using the Southern blot method final1y confirmed that this was a B cell-type lymphoma.

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The authors report a child with moyamoya disease who repeated acute progression of major arterial stenosis on the contralateral side after two-staged vascular reconstructive surgery. An 8-year-old boy had frequent transient ischemic attacks involvlng the left extremities starting at 4 years of age. Cerebral angiogram revealed right internal carotid artery (ICA) occlusion and typical moyamoya vessels in the right basal ganglia, while left anterior cerebral artery (ACA) and middle cerebral artery (MCA) showed only stenotic configurations without moyamoya vessels. Cerebral blood flow (CBF) measurement using 133Xe SPECT demonstrated low CBF and negative response to Diamox loading in the territories of the right MCA, ACA, part of the posterior cerebral artery (PCA) and the left ACA. We initially perfonTled indirect reconstructive surgery on the affected right MCA and ACA territories, followed by cerebral infarct In the left frontal lobe 34 days after surgery due to left ICA occlusion. One month later, we added left STA-MCA anastomosis, followed again by cerebral infarct in the right occipital lobe I month after surgery due to right PCA occlusion. Thus, we underscore the necessity for careful postoperative observatlon of progressive major arterial stenosis using magnetic resonance angiography in pediatric patients with moyamoya disease undergoing indirect or direct reconstructive surgery of I hemisphere. In such patients, performing one-staged extensive indirect reconstructive surgery may be prudent, covering whole areas where preoperative CBF measurement revealed low CBF at rest and impairment of vascular reactivity on Diarriox loacling.

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A 2-month-old girl developed macrocephaly and the setting sun phenomenon. CT scanning revealed marked dilatation of the lateral third ventricle. Midsagittal MR imaging failed to reveal the proximal portion of the cerebral aqueduct, and axial MR imaging at the level of the mesencephalic tegmentum revealed aqueduct narrowing. Endoscopic third ventriculostomy (III VS) was performed successfully at the age of 3 months, after whlch symptoms of elevated intracranial pressure disappeared rapidly. Now 14 months of age, the infant has so far performed normally on developmental screening tests. Unlike severe fetal-onset hydrocephalus, it is thought that reopening of the subarachnoid space could occur easily in this patient after 111 VS. However, head circumference gradually increased after 111 VS, and only moderate ventricular enlargement and brain atrophy remained. 111 VS is less effective in reducing ventricular size than shunt placement. The effects of neuronal reorganization and maturation in cases of infantile hydrocephalus after 111 VS have not yet been clarifled.

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