Severe head injuries as surgical insults, burn and sepsis, have been reported to induce hypermetabolic and hypercatabolic states with the accompanying hormonal changes. However, nutritional management has tended to be rather underestimated, while the potential risk of hyperalimentation against critical intracranial pressure(ICP)has been stressed. In this study, 2 weeks of aggressive nutritional support was adopted for 24 patients with severe head injuries(GCS&InE;8)under ICP monitoring, and its influence on ICP or its effects on various nutritional and immunological parameters were assessed. Eight cases dropped out from this study ; 5 cases fell into brain death within 4 days due to intracranial hypertension, and severe hyperglycemia could not be controlled in an other 3 cases. In 5 cases, out of the remaining 16 cases, who tolerated our hyperalimentation regimen well(more than 18g nitrogen/day, 2, 900〜3, 750Cal./day), the proper nitrogen balance, serum protein level and muscle volume could be kept. In contrast, in the 11 cases who received less than 18g nitrogen/day showed a negative nitrogen balance and muscle volume loss. No adverse effect on ICP was detected from the hyperalimentation, unless intractable electrlytes disorder or hyperglycemia occured. Septic pulmonary complications were seen in 2 cases, to whom enteral administration was started within 7 days. Aggressive nutritional management in cases with severe head injuries from an early stage can be carried out safely under strict electrolyte and blood suger control. The favorable effect of hyperalimentation therapy on metabolic status was shown in this study.

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Chronic subdural hematomas is one of the most common diseases in neurosurgery, and there have been numerous clinical and experimental studies concerning the etiology, the mechanisms of their development, especially their increase in size of chronic subdural hematomas have remained controversial. In order to study the mechanisms of increase in size of chronic subdural hematomas, we observed HE stained and immunohistochemically stained vascular endothelial growth factor(VEGF)(vascular permeability factor)and its receptor in outer membranes of chronic subdural hematomas. VEGF is a factor for angiogenesis and vascular permeability resulting from endothelial cells proliferation. The outer membrane of chronic subdural hematomas was composed of infiltrating cells such as fibroblasts, endothelial cells, lymphocytes, and eosinocytes. VEGF was expressed in the endothelial cells and infiltrating cells, and its receptor was also seen in the endothelial cells and their adjacent infiltrating cells. So it is suggested that VEGF is one of the most important factor for the mechanism of the increase in size of chronic subdural hematomas.

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The patient was a 42-year-old male who presented with an arteriovenous malformation(AVM)in the left temporal lobe. The onset occurred during an epileptic seizure, and the AVM measured 5.4cm in size. At first, embolization was performed, but after embolization, an intranidal aneurysm was also observed. We could not perform an embolization of the aneurysm. Two weeks later, angiography was performed and showed an occlusion of the draining pathways. We performed radiosurgery on the nidus which measured 2.7cm in size. The patient demonstrated no deficit at the time of discharge. Five months later, however, he suddenly suffered from a massive cerebral hemorrhage, and died. This case reinforces the fact that surgery should be performed for an AVM with either an occlusion of the draining pathways or with an intranidal aneurysm.

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Nerve block therapy has been used for pain control with effective results. Lumbar anesthesia has slso been a useful method of anesthesia for several kinds of operations. However, these procedures are administered with needle puncture and include several serious complications such as infection, nerve injury or hematoma formation, possibly resulting in serious neurological deficits. In the present study, the authors reported 3 cases of hematoma formation following nerve block therapy or lumbar anesthesia. Case 1 showed an epidural hematoma at the L2-L3 level after epidural nerve block. Case 2 showed retropharyngeal hematoma formation after stellate ganglion block. Case 3 showed a subarachnoid hematoma following lumbar anesthesia resulting in acute paraplegia. Case 1 and Case 2 were conservatively followed up and Case 3 was treated by laminectomy and hematoma removal. The effectiveness of MRI in detecting hematoma formation following nerve block therapy was reported and the treatment modalities for these complications were discussed.

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We presented a case of direct injury to most of the corpus callosum(anterior four fifths)caused by an aneurysmal rupture at the distal ACA(anterior cerebral artery). A 65-year-old woman was transferred to our hospital because of mental confusion and right hemiparesis. Cerebral angiography showed a ruptured distal ACA aneurysm. She had a neck clipping of the aneurysm through an interhemispheric approach performed on day 0 and was rated as grade IV on World Federation of Neurological Societies grading scale. The patient was observed postoperatively through detailed neurobehavioral and neuropsychological examinations, serial brain MRIs(magnetic resonance imaging)and brain SPECTs(single photon emission computed tomography). Good correlation was observed between her neurological improvement and the serial neuroimaging of MRI and SPECT. Brain MRIs showed progressive atrophy of the genu and trunk of the corpus callosum associated with an extensive change of the bilateral corona radiata. A gradual improvement of cerebral blood flow on brain SPECT, especially in the bilateral basal ganglia and frontal lobe reflected an amelioration of her neuropsychological and psychophysical status. Her disconnection syndrome was caused by a direct injury of the callosal fibers due to the aneurysmal rupture. Her remaining neurological deficits were memory disturbance, confabulation, disorientation, aprosexia, sensory apraxia, and mild right hemiparesis. Serial organic changes in the surroundings of the corpus callosum were demonstrated in detail by brain MRI, and the gradual improvement of her clinical features was closely related to the improvement of blood flow on brain SPECT.

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We report a case a 43-year-old man who had a cerebral cortical venous thrombosis who first presented with headache. A CT scan on admission, revealed a low density area in the right insula cortex around the sylvian fissure, and a CE-CT scan showed a heterogeneous enhancement at that lesion. A right carotid angiogram showed both an arteriovenous shunting(A-V shunting)and a partial defect of the cerebral cortical vein at this lesion. A month after admission, the A-V shunting was gone and recanalization of the thrombosed vein was achieved following repeated right carotid angiograms. MR venography(MRV)showed that the straight sinus drained into the left narrow transverse sinus, that the superior sagittal sinus drained into the right large transverse sinus, and that the bilateral transverse sinuses did not communicate with each other at the torcular Herophili. The MRV revealed this anatomic variation in detail. It was difficult to make a diagnosis of cerebral venous thrombosis, as we could not be sure of the cause. But we think that A-V shunting is a significant finding at the site of the cortical venous thrombosis.

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We report a case of traumatic facial palsy that was treated successfully by cross-face nerve transplantation. A 16-year-old female was injured by motor cycle accident. She showed severe left facial palsy accompanied with the petrous bone fracture. At first, she was treated conservatively by facial massage, but her symptom didn't improve at all. She underwent cross-face nerve transplantation for her facial palsy 3 months after the injury. Her symptom improved rapidly 6 months after the operation. She regained facial muscle tone and voluntary movement gradually, and emotionally-induced spontaneous movement was evident by 12 months after the operation. Cross-face nerve transplantation has an advantage in restoration of emotional facial movement, though requiring considerable surgery and a long delay in reinnervation. This procedure is useful in the treatment of facial palsy especially in young patients who have a symptom of short duration.

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Extensive bone defects producing cosmetic problems are routinely repaired with a ceramic bone flap. The bone flap is designed with the help of computerized technology. However, a rigid fixation of bone flap is difficult because titanium screws cannot be easily used with ceramic. The authors developed a new method for fixing ceramic bone flaps. At the designing stage, 3 small tenons are added to the corner of the bone flap. During cranioplasty, 3 mortises fitting exactly the projections are drilled with a diamond. The final fixation is made with wires which provide a rigid anchoring preventing rotation, pullout and/or sinking. There is growing concern about the effect of cranial defects on the patient's cosmesis, comfort and brain protection. Our method contributes to good cosmetic outcome, especially in the case of cranial defects involving the forntotemporal region.

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