Idiopathic normal pressure hydrocephalus (INPH) in aged people is one of major concern in Japan where the rate of aging among the overall national population is rapidly increasing. Here, we report the results of a cooperative study on the early and late effects of CSF shunt in INPH in patients over 65 years old. Questionnaires were sent to 14 members of the Research Committee of "Intractabel hydrocephalus", the Ministry of Health and Welfare of Japan. The early effects of CSF shunt (within 3 months of CSF shunt) was assessed in cases treated during the last 3 years. A second study was performed for assessing the long-term effect of CSF shunt which was done before the end of December 1997. One hundread and twenty cases were collected for the first study and the mean age was 72 years. VP shunt was conducted in 87.5% of cases and about three quarters of them were treated with programmable valve. Improvement of symptoms was obtained in 80% of the cases in the early assessment. Improvement of gait disturbance was most evident and most frequent. However, the early high efficacy decreased to 66% due to shunt complications in 18% of cases and of extra-shunt complications in 16%, even in assessments up to 3 years (mean 15.7months). One hundred and thirty cases were collected for the second study. The mean age was 70 years and the mean follow-up duration was 31 months. Long-term improvement was noted in 60% of the cases and their mean duration was 29 months, with a maximum of 10 years. Thus, a high success rate in the early stage of CSF shunt in INPH in aged people was noted. This may be due to precise diagnosis and a high prevalence of programmable valve. The shunt effect can be maintained more than 2 years and half us to 10 years. Further study is necessary for long-term improvement of symptoms in INPH, which would provide a better quality of life to aged people.

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The terminology of "NPH" is in a confusional state in which hydrocephalus occurring in adulthood are almost all included. It comes mainly from the original terminology which Hakim and Adams in 1965 defined this type of hydrocephalus, with specific clinical features in cognition or dementia, based on the pathophysiological understanding but not from the symptomatological aspects. Since the extensive analyses have been made with the use of continuous intracranial pressure (ICP) monitoring in last 30 years, it became appearant that the terminology of "NPH" is not proper and this clinical entity should purely defined in its characteristic symptomatological aspect. Ten cases of idiopathic hydrocephalus in adults were analyzed in light of shunt CSF flow rate and type of shunts applied in variety of ICP dynamics. The shunt systems applied were medium-pressure in 5, low-pressure in 3 and unknown in 2 patient (s). The shunt system was needed to be changed in 2 patients, 1 from medium-to low-pressure and 1 from low-to medium-pressure system because of either under-drainage or over-drainage problem, respectively. Seven patients were improved clinically, but there was no correlation between the shunt CSF flow rate and the shunt system pressure among the cases, or between the clinical improvement and volume of the shunt CSF flow. Along with "hydrocephalus chronology in adults" staging (HCA Stage I-V, Oi, 1998), it was also noted that "hydrocephalic dementia ; HD" occurred during HCA Stage-II, Stage-III and Stage-IV. Since the unique clinical symptoms of dementia, urinary incontinence and gait disturbance proposed by Hakim and Adams as "NPH syndrome" are not specific to the ICP dynamics, it was emphasized that the term of "NPH" should not be applied simply from the symptoms of dementia. The selection of shunt system, mainly in the differential pressures, should be based on the specific ICP dynamics or HCA Stage in the individual patient.

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The authors report a case of a 50-year-old female patient with metastatic brain tumor at the tent as an underlying disease who had transient MLF syndrome triggered by generalized convulsions occurring when brain edema was exacerbated. The patient was admitted after convulsive seizure occurred, and MLF syndrome was revealed after the consciousness disturbance improved. MLF syndrome improved after about two months. The neuroanatomical region of MLF is considered in the watershed area covering paramedian branches and circumference branches of the basilar artery, which are the most liable to cause cerebral ischemia hemodynamically. These findings suggest that brain stem distortion and/or increased ICP caused by the supratentorial tumors could be MLF syndrome triggered by convulsive seizures, in which the MLF region became ischemic due to circulatory failure of the basilar arterial branches.

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A 56-year-old man who suffered from vertigo and vomiting was admitted to our hospital. Physical and neurological examinations showed no abnormalities. CT scan revealed a ringed calcified mass compressing the pons. MRA and MRI revealed a non ruptured large mid-basilar trunk saccular aneurysm, 22m×15×14mm in diameter, with a small neck, 4mm in diameter, without apparent thrombus formation. The aneurysm was thought to be an arteriosclerotic ectatic aneurysm because angiogram revealed the aneurysm had no relation to the arterial forks with considerable sclerosis of the basilar artery. Endovascular surgery was performed because the aneurysm had not ruptured and direct surgery seemed to be risky. The aneurysm was almost completely occluded by 20 pieces of Guglielmi detachable coil with preservation of the parent artery. Angiogram 12 months after embolization revealed almost complete occlusion of the aneurysm without recanalizaion. The patient had been free of the symptoms since embolization. Therefore, we thought the symptoms were caused by pulsation from turbulent flow in the aneurysm. Afrer embolization pulsation diminished and the symptoms disappeared. A large mid-basilar saccular aneurysm is very rare and is very difficult to treat by direct surgery. Endovascular treatment using GDC is safe and useful for such a large aneurysm with a small neck, especially in the posterior fassa.

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We report a rare case of recurrent Langerhans cell histiocytosis (LCH) presenting as a scalp ulcer. A 2-year-old boy underwent total removal of a left frontal bone tumor on August 8, 1996. Histological diagnosis of this tumor was LCH. Around January of 1997, the wound was infected, forming an abscess which was probably caused by extension of frontal nasal sinusitis. The abscess was incised and the pus was drained. Administration of antibiotics was started immediately, but the condition was aggravated, resulting in the ulcer formation. Wound debridement was tried several times, but resulted in failure each time. As biopsy of the bottom of the ulcer disclosed the recurrence of LCH, three courses of chemotherapy consisting of Ara. V.P. therapy (cytosine arabinoside, vincristine and predonisolone) were given. This resulted in complete healing of the wound. The mechanism of the ulcer formation by recurrent LCH is discussed.

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