In observing the sequential change of cerebral blood flow (CBF) of 44 patients with hypertensive intracerebral hemorrhage, we have studied the relation of CBF, treatment, and neurology. Of those 44 patients, 26 had a putaminal hemorrohage, and 18 had a thalamic hemorrhage. A stereotactic aspiration surgery was performed on 9 patients with putaminal hemorrhage and on 7 patients with thalamic hemorrhage. The patients for our study were selected by using the following criteria: (a) no history of cerebrovascular or cardiopulmonary diseases, (b) a neurological grading (Kanaya 1978) between 1 and 3, (c) a hematoma volume less than 45 ml, and (d) under the age of 70. Mean cerebral hemisphere blood flow was measured with <123>^I-IMP SPECT with arterial blood drawing within 1 week, 2 weeks, 4 weeks, 8 weeks, and then 6 months after the onset, respectively. Those patients whose neurological condition did not improve during the first week after the onset were operated on with stereotactic aspiration surgery. The results of the sequential change of CBF were as follows: Bilateral CBF in the non-operated group of putaminal hemorrhage was reduced from 0 week to 2 weeks, and from 4 weeks to 8 weeks after the onset. It then showed a tendency to increase from 8 weeks to 6 months. Bilateral CBF in the operated group of putaminal hemorrhage was low at the onset. With a temporary increase after the operation, the bilateral CBF decreased from 2 weeks to 4 weeks after the onset. It then showed a tendency to increase from 4 weeks to 6 months. Bilateral CBF both in the operated and non-operated groups of thalamic hemorrhage was low at the onset. It then increased from 2 weeks to 4 weeks, but showed a tendency to decrease from 4 weeks to 6 months. With regards to the putaminal hemorrhage, it was found that the initial neurological grading correlates with CBF value. Aspiration surgery was effective in recovering hemiparesis of those patients with putaminal hemorrhage whose initial CBF value was low and whose posterior limb of the internal capsule was not impaired. With the thalamic hemorrhage, neurological grading was found to correlate, not with CBF value, but with hematoma volume. Compared with the putaminal hemorrhage, reduction of CBF stayed chronic, and aspiration surgery was not effective for the thalamic hemorrhage.

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Primary intraventricular hemorrhage (PIVH) is defined as a bleeding restricted in the ventricular system without an intraparenchymal hematoma. However, the etiology and clinical characteristics of PIVH remain unclear because of it's low incidence. Fifteen patients with PIVH were retrospectively studied concerning the clinical features, risk factors and prognosis. We investigated the clinical symptoms, medical histories, radiological findings and outcomes of these patients. Neither cerebral angiography nor magnetic resonance imaging showed abnormal findings closely related to an intraventricular hemorrhage in any patient. The volume and extent of the intraventricular hematoma were estimated by CT score (Graeb score). The most frequent symptom was consciousness disturbance (86.7%), which was clearly correlated with the Graeb score. In particular, the patients with hematoma expanding to the 3rd and /or 4th ventricle showed a poor consciousness level. The ages and past histories were not related to the consciousness level at the onset. Seven patients received external ventricular drainage with intraventricular urokinase infusion in 2 patients. One patient died of acute renal failure. Of the survivors, 9 patients exhibited good recovery (60.0%), and 4 patients recovered to moderate disability (26.7%). One patient had a poor outcome due to gastrointestinal bleeding. The amount of hematoma did not influence the outcome, however, the presence of hematoma within the 3rd and / or 4th ventricle tended to worsen the outcome. Moreover, the medical history was a more important risk factor for the outcome than the patient's age. We concluded that extensive treatment may improve the outcome even in patients with severe PIVH or elderly patients.

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A patient with life threatening thalamic pain was successfully treated with chronic motor cortex stimulation. A 66-year-old female had a stroke with residual right hemiparesis 12 years ago. Three years later, she developed a constant aching pain involving her face and arm on the right side. Many modalities, such as anticonvulsants, antidepressants, acupuncture, and dorsal column stimulation had been tried, but failed to achieve pain relief. Although her right hemiparesis was moderate, she had become bedridden, and had undergone a gastrostomy to prevent her oral pain. Her pain was resistant to a morphine test. Magnetic coil stimulation of the motor cortex relieved her pain for 30 minutes. An electrode array was implanted epidurally above the left motor cortex under local anesthesia. Chronic motor cortex stimulation has provided about 70% relief from the pain for more than 6 months. We emphasize that chronic motor cortex stimulation should be attempted for thalamic pain before ablative procedures. Magnetic coil stimulation is strongly recommended for predicting a favorable response to this treatment.

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A case of primary intracranial germinoma involving pituitary stalk, corpus callosum and periventricular tissue of the frontal lobe, the size of which was markedly decreased after steroid therapy, is reported. A 28-year-old male presented with diabetes insipidus, then he developed intracranial hypertention and visual disturbance. To reduce massive edema surrounding the tumor, 1, 000mg of methylprednisolone was administrated intravenously for 4 days. MRI obtained 47 days after completion of the treatment revealed dramatic regression of tumor itself in addition to diminished edema. Antineoplastic effect of corticosteroid for intracranial germinoma is discussed.

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A 4-month-old female baby was admitted to our hospital because of loss of consciousness with convulsions. When the baby was lifted up and dangled several times by her father, her neck jerked forwards, backwards and sideways and she suddenly lost consciousness and went into convulsions. About 1 month earlier, her father had done the same, but stopped when she cried out. CT scans revealed not only an acute subdural hematoma extending along both occipital lobes and the interhemispheric fissure, but also a chronic subdural hematoma on the left hemisphere. The chronic subdural hematoma was thought to have been caused when the baby was shaken 1 month earlier. A diagnosis of accidental shaken baby syndrome was made because there was no proofs of nonaccidental child abuse. Since the patient quickly recovered consciousness and her neurological condition was not so severe, except for the bilateral retinal hemorrhages, the hematomas were treated concervatively and the patient was discharged from the hospital 3 weeks after ictus. It was well known that shaken baby syndrome is often caused by child abuse and the outcome is generally not good. Therefore it is important to fully investigate, by examination of the onset and course of the illness, suspecting child abuse when an acute subdural hematoma with traumatic subarachnoid hemorrhage is seen in a child.

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We describe a case in human of the combined application of endovascular stent implantation and Guglielmi detachable coil (GDC) packing in the management of a wide-necked intracranial aneurysm. A 48-year-old woman with vertebral artery aneurysm presented with subarachnoid hemorrhage. The left vertebral angiography showed a wide-necked aneurysm at the vertebral artery and the posterior inferior cerebellar artery divided just proximal to the neck. The neck of the aneurysm is 8mm long, and the dome size is maximum 13mm. Because of the size of the aneurysmal neck and aneurysm location on angiograms, it was deemed unsuitable for surgical intervention or for conventional endovascular coiling. A balloon-expandable stent was placed across the neck of the aneurysm to act as a buttress against which GDCs could be packed. Immediately after embolization, angiography showed the patency of the left vertebral and posterior inferior cerebellar artery, and the aneurysm was completely occluded. After endovascular treatment, the patients suffered no complications attributable to this procedure. In conclusion, this evolving technology may play a role in the near future as an alternative of choice in some cases of aneurysm treatment via the endovascular route especially in wide-necked aneurysm.

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We report a case of subarachnoid hemorrhage (SAH) due to ruptured aneurysm in the course of Klinefelter syndrome and systemic lupus erythematosus (SLE). The case was a 49-year-old male who suffered from SLE for 16 years. He noticed sudden severe headache and vomiting, and was admitted to our hospital. The CT scan revealed SAH. The cerbral angiography showed a saccular aneurysm of the anterior communicating artery and a stenotic lesion of the left middle cerebral artery. The patient underwent the neck clipping of the aneurysm and was discharged with no neurological deficits about 2 months after admission. The test for antiphospholipid antibodies was positive in his serum. This is the first report of a ruptured aneurysms in a patient with SLE and Klinefelter syndrome with antiphospholipid antibodies. These findings suggested that the aneurysm formation in SLE might be related to the antiphospholipid antibody and the chronic estrogen stimulation in Klinefelter syndrome might have affected the production of autoantibodies.

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A 68-year-old male was admitted to our hospital complaining of exophthalmos of the right eye and double vision. Computerized tomography (CT) of the orbit and magnetic resonance image (MRI) showed a mass lesion in the superolateral area of the right orbit. The orbital tumor was managed by fronto-temporal craniotomy, and the right orbitotomy had to be added because the tumor was densely adherent to the internal plate of the orbit. The tumor was so soft that it could be subtotally removed by aspiration. Histopathological examination of the aspirated tumor tissue was diagnosed to be a hepatocellular carcinoma. Postoperatively, abdominal CT scan and echogram demonstrated a tumor mass in the liver, and the diagnosis of hepatocellular carcinoma was confirmed. The patient, however, refused further therapeutic procedures as he had no subjective symptoms of the liver tumor, and was discharged with almost complete recovery from the initial symptoms of exophthalmos and double vision. We reported our case and reviewed some literatures of orbital metastasis of hepatocellular carcinoma.

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