For the last several years, we have been treating vesospasm with a combination therapy of intravenous highdosage nicardipine and an intraarterial infusion of papaverine (IAP). In some cases, we have gotten satisfactory results from IAP, but in other cases, the results have been less favorable. In order to determine the predictive factors of our results, we performed a retrospective study of cerebral circulation before and after IAP based upon dynamic DSA. Eighty-four patients with a diagnosis of ruptured intracranial aneurysm were treated with prophylactic nicardipine therapy. Twenty-eight of these 84 patients underwent IAP for symptomatic vasospasm. In 19 of these 28 patients, the mean transit time (MTT) based upon dynamic DSA data was extrapolated by gamma formula before and after papaverine infusion. The MTTs of the control group were 4.53±0.21 (mean±SD) seconds on the right hemisphere and 4.70±0.42 seconds on the left side. The MTTs of group A, for which IAP therapy showed a dramatic effect, were 5.20±0.54 seconds before IAP and 4.15±0.35 seconds after. Those of group B, for which IAP therapy showed a fair effect, were 5.56±0.71 seconds and 4.31±0.60 seconds, respectively. Those of group C, for which IAP therapy showed no effect, were 6.71±1.62 seconds and 4.63±0.38 seconds respectively. The MTTs before IAP were significantly longer in group C than in group A (p<0.05). In all cases, IAP therapy improved cerebral circulation based upon dynamic DSA study (p<0.01). But the shortening of MTTs after IAP therapy dose not always guarantee the good clinical results. Better clinical results may be expected the shorter the MTT velues before IAP therapy.

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We present the surgical experiences of 99 (49 male, 50 female) patients ranging in age from 1 month to 52 years who were afflicted with lumbosacral lipomas. Preoperatively, 36 of the 99 were diagnosed as being neurologically intact while the remainder had verious neurological sequelae including reflex change, sensory disturbance, muscle weakness, and sphincter disorder. Preoperative neuroimaging permitted classifying lumbosacral lipomas into 5 categories : (1) dorsal, (2) caudal, (3) combined, (4) filar types, and (5) lipomyelomeningocele. Although all 99 patients untederwent unthering of the spinal cord, some lipomas remained untouched upon completion of surgery to avoid risks of injury to nervous tissues with respect to combined type lipomas and lipomyelomeningoceles. The lipoma could, on the other hand, be removed either subtotally or completely to untether the spinal cord in cases of caudal and filar type lipomas, and most dorsal type lipomas. In a mean postoperative follow-up period of 8.49 years, there was no significant deterioration among most patients, and some patients even demonstrated improved function. Four patients, however, developed bladder function deterioration postoperatively, 3 of them in a late-onset manner although unethering surgery successfully had been accomplished at between 3 and 4 months after birth. Our results indicated untethering surgery possibly could prevent neurological function deteriorating with advancing age in most patients with lumbosacral lipomas, but not for some patients even though the spinal cord was untethered during the early post-birth period.

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Nine patients were treated with Ca channel blockers by continuous intravenous infusion for perioperative management of intentionally delayed surgery. Six patients had unexpected complications such as decreased urine output and decreased saturation of blood oxygen. Those effects increased with dosage of the agents. Daily urine output was extremely increased several days after surgery probably due to discontinuation of the agents. We must consider those side effects when using Ca channel blockers for perioperative management of hypertensive subarachnoid hemorrhage patients.

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A case of acute demyelinating disease mimicking a brain tumor is described. A 22-year-old woman was admitted to our hospital for evaluation of left homonymous hemianopsia. Computed tomography and magnetic resonance imaging (MRI) revealed an irregularly enhanced lesion with a marked mass effect in the right parietooccipital lobe. Subtotal excision of the mass lesion was then performed by craniotomy on the basis of a preoperative diagnosis of malignant glioma. However, histological examination of the specimen revealed the typical features of demylinating disease, including infiltration of lymphocytes in the perivascular space and demyelination. A follow-up MRI examination 2 years later revealed no evidence of recurrence of the lesion. Although demyelinating disease menifesting as an irregular mass lesion with a marked mass effect is uncommon, it is important that it be differentiated from a brain tumor.

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In the surgical treatment of basilar trunk aneurysm, there is still considerable difficulty in gaining both proximal artery control and a sufficient operative field. To overcome these problems, we used a neuroendoscope in a case with this type of lesion. A 68-year-old woman was admitted at our hospital after an episode of severe headache. CT showed a subarachnoid hemorrhage predominantly located in the perimesencephalic cistern. Angiography revealed an aneurysm in the distal one-third of the basilar trunk. The lesion was reached via a right subtemporal transtentorial approach. When the tentorium was incised, the operative field was occupied by a dome of aneurysm of 1.2cm in diameter. An endoscope (Clarus Murphy Scope, 2125-157) allowed the visualization of the vertebral arteries proximally, and the superior cerebellar artery distally. Furthermore, after verifying that there were no perforators branching from the basilar trunk, we placed a clip. The patient had an uneventful clinical course except for a normal pressure hydrocephalus which required installation of a VP shunt. We would like to stress the efficacy of neuroendoscopy especially in such a case with this rare and deep seated lesion.

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The patient was a 4-month-old boy who presented after 1 month of vomiting. Examination showed bulging of the great fontanelle. MRI demonstrated an enhancing tumor in the cerebellar vermis accompanied by hydrocephalus. The tumor was subtotally resected, however, the patient succumbed 6 months postoperatively due to rapid growth of tumor. Pathologically, this highly cellular tumor consisted of monotonous proliferation of cells without showing origanoid patterns in most part of the tumor. Many tumor cells had round nuclei with scant cytoplasm. Also present were larger cells with voluminous eosinophilic cytoplasm, and vesiculated nuclei with prominent nucleoli. To a limited extent, the tumor featured cell arranged around blood vessels and forming microcysts lined with cuboidal epithelium were present. Neoplastic mesenchymal tissues were not observed. There were some necrotic foci and abundant mitotic figures in the tumor. Immunohistochemical study for GFAP, neurofilament, Tuj-1, synaptophysin, EMA, vimentin, CAM 5.2, smooth muscle actin, desmin and myoglobin was performed. Many tumor cells were positive for vimentin, EMA and CAM 5.2. Clusters of tumor cells were also positive for GFAP. Small number of tumor cells were reactive for smooth muscle actin, synaptophysin, neurofilament and Tuj-1. Ultrastructurally, tumor cells frequently showed well developed intercellular junctions, microvillous protrusions and cilia, suggesting the presence of ependymal differentiation. The present case is consistent with AT/RT, however, a feature of ependymal differentiation has not been observed in Dr.Rorke's series. The case deserves to report and may help in the understanding of childhood embryonal tumors including AT/RT.

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We report 2 cases of neurofibromatosis type I associated with left orbital dysplasia. The first case was a 19-year-old male who had suffered from a progressive pulsating exophthalmos of the left eye and a subcutaneous neurofibroma of the left scalp since childfood. No family history of neurofibromatosis was apparent. The second case was a 13-year-old female with cafe au lait spots who had suffered from left blepharoptosis and palpebral edema since brith. A pulsating exophthalmos in her left eye was first noted at the age of 6 years. Her mother also suffered from the same disease. In both patients, skull X-ray films and three-dimensional computed tomography revealed defects in the posterior wall of the left orbit, major wing of the left sphenoid bone, left anterior clinoid process, and sella turcica. Different methods were used to repair the bone defects in the two probands. In the first patient, after left frontotemporal craniotomy, the posterior orbital wall defect was covered with a resin plate through the extradural space. In the second patient, the bone defect was covered with 6 pieces of Teflon^[○!R] felt through the intradural space at the region of the temporal pole. The pulsating exophthalmos of each patient was reduced after surgery. The second treatment approach was easier to perform and safer because the cranial nerves could be identified directly.

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A case of cerebellopontine angle lipoma presenting as trigeminal neuralgia is reported. The 22-year-old male patient had been experiencing neuralgia in the right first and second branches of the trigeminal nerve for the previous 2 years. He exhibited no other neurological deficits. Magnetic resonance (MR) imaging revealed a lipoma in the right cerebellopontine angle. Lateral suboccipital craniectomy was performed and a lipoma was found to be abherent to the cisternal portion of the right trigeminal nerve. Partial removal of the tumor from around the root entry zone of the nerve relieved the neuralgia. The patient recovered well after surgery. He is currently free from trigeminal neuralgia. Given the difficulties associated with total tumor removal without causing neurological deficits, as well as the slow growth rate of such tumors, only a partial removal of tumors at the root entry zone of the trigeminal nerve is recommended in patients with lipoma-induced trigeminal neuralgia.

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We report two cases requiring occipito-cervical fixation in which the SPINE-system^[○!R] cervical was used. The first case was that of a 71-year-old man, who had suffered a typeII odontoid fracture in a traffic accident. The other was a 65-year-old man, with metastatic hepatocellular carcinoma to C3 and C5 and severe neck pain and radiculopathy. In both cases symptoms improved after the operation and good stabilization was achieved with the SPINE-system^[○!R]. This system especially useful for occipito-cervical fixation which needs for vertical distraction and compression force.

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Although cell saver systems have not been commonly applied in neurosurgery, we now describe a patient with catastrophic bleeding, as a result of premature rupture of a basilar bifurcation aneurysm, whose life was saved by autotransfusion with shed blood with the use of such a system. The patient was a 64-year-old man who was transferred to our hospital because of mild subarachnoid hemorrhage. A small aneurysm was detected at the bifurcation of the basilar artery by cerebral angiography. When the neck of the aneurysm, which resembled a blister, was exposed through right transzygomatic surgery, premature rupture occurred. The neck of the aneurysm was torn off, resulting in catastrophic bleeding. Although homologous blood was transfused, the bleeding continued. However, the bleeding was controlled after transfusion of about 4, 000 ml of autologous blood with a cell saver system. Such systems should thus be considered for use in aneurysmal surgery.

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