A case of the occlusion of the cervical internal carotid artery associated with intracerebral steal phenomenon is reported.
A forty-five year old man was admitted complaining of hearing disturbance and tinnitus on the left side. He had twice episode of general convulsion following Jacksonian marching. Computed tomography disclosed no significant finding. Angiograms revealed complete occlusion of the right internal carotid artery (ICA) at the cervical portion. The vertebral angiogram showed the filling of the right internal carotid territory bia posterior communicating artery with the filling of the vertebr-basilar territory.
We concluded that these auditory symptoms had been caused by the intracerbral steal mechanism between the right ICA and the vertebro-basilar territory. The extracranial-intracranial bypass was performed on the right side. Soon after the operation auditory symptoms were significantly improved. Postoperative angiograms indicated the enough filling of the right internal carotid territory from the right superficial temporal artery. After the discharge, the former auditory symptoms were complained again because of the compression for the donor artery with the frame of the glasses. The release of the compression improved those symptoms.
According to these results we believed that his auditory symptoms caused by the intracerebral steal phenomemon between the internal carotid territory and vertebro-basilar territory.
Hearing disturbance and tinnitus are popular symptoms. They may be thought as an important clue of the cerebrovascular disorders.

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The purpose of this paper is to elucidate clinical characteristics in subarachnoid hemorrhage (SAH) following rupture of a distal anterior cerebral artery aneurysm (DACA AN). Subjects were 29 patients (13 male, 16 female) of the ruptured DACA AN who were admitted from 1976 to 1986. Mean age of them was 55 years. The incidence of the ruptured DACA AN was 4.1% out of all the patients with a ruptured aneurysm during these 10 years. Computed tomography and angiography was performed in all of them on admission and followed in 20 patients with surgical treatment. Follow-up (mean time : 3.4 years) was performed to evaluate outcomes. Azygos ACA was seen in 6 patients (21%) out of the 29. Multiple aneurysms were demonstrated in 10 patients (34%) out of them, and out of the 15 incidental aneurysms, nine (60%) were in the territory of the ACA. These findings suggest that hemodynamic stress may play an important role in the formation, growth and rupture of the DACA AN.
Intracerebral hematoma (ICH) were seen in 15 patients (52%) out of the 29. Out of the 9 patients with conservative treatment, 8 dead patients showed the following consciousness level on admission : stupor in one, semicoma in 2, coma in one, deep coma in 4. Another surviving patient, who refused aneurysmal operation, showed clear consciousness on admission. Most of the former 8 had either large ICH or massive intraventricular hematomas (IVH). On the other hand, outcomes of the 20 patients with surgical treatment were as follows : fully recovered in 13, self-managing in 2, partially dependent in one, fully dependent in 2, dead in 2. Preoperative consciousness level was clear in 15, drowsy in 2, stupor in one, semicoma in one and coma in one. Eighteen patients out of the 20 had either no or small ICH, while the another patient of coma had large ICH. From these findings, the clinical course of the ruptured DACA AN seems to be divied into 2 groups : fulminant SAH group, developing severe consciousness disturbance soon after SAH, associated with large ICH and massive IVH, resulting in poor outcomes whether the operation is performed or not; mild SAH group, having less than mild consciousness disturbance and small ICH, following good outcomes after the operation.

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Free fatty acids, which increase during brain ischemia, exert profound effects on the subsequent brain cell injury, and calcium (Ca²⁺) is considered to be involved in the production of these free fatty acids. On the other hand, binding assays or autoradioagraphic studies have established the presence of dihydropyridine (DHP) binding sites in the brain tissue. In this study, we examined the effects of YC-170, a synthetized Ca²⁺ agonist, on the liberation of free fatty acids in the ischemic rat brain using the decapitation model. The results show that the YC-170 accelerates the liberation of free fatty acids significantly. These findings seem to indicate that the Ca²⁺ influx via the DHP sensitive channel influences cerebral phospholipid metabolism during ischemia, and also seem to provide supportive evidence of the protective effects of the DHPs against ischemic cell injury on the brain.

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Relationship between the volume of putaminal hemorrhage in acute stage and ipsilateral CBF in chronic stage was investigated on surgical group (14 cases) and conservative group (16 cases). The volume of hematoma was calculated by the high density area demonstrated on brain CT scan within 24 hours after the onset. CBF was measured 1 to 6 months after the onset with ¹³³Xe inhalation method expresseing by initial slope index.
The volume of hematoma ranged 15 to 84 ml in surgical group, and 5 to 50 ml in conservative group. In conservative group. negative correlation between the volume of hematoma in acute stage and CBF in chronic stage was significant (r=-0.60, p<0.05), but there was no correlation in surgical group (r=-0.36). In the hematoma of 15 to 50 ml, mean values of CBF in the surgical group (11 cases, 36.4 ± 7.1 ml/100 g/min) did not significantly differ from that in the conservative group (11 cases, 37.8 ± 8.1 ml/100 g/min). In 3 operated-patients with hematoma over 50 ml, however, CBF (30.9 ± 5.2 ml/100 g/min) preserved beyond expectation from negative correlation in conservative group. Furthermore there were no differences in ADL and intellectual performance between surgical group and conservative group.
It was suggested that surgical treatment was not superior to conservative treatment for cerebral blood flow and for ADL in putaminal hemorrhage less than 50 ml, but might be superior in the hematoma more than 50 ml.

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Enolase is a dimetric enzyme which catalyses the interconversion of 2-phospho-D-glycerate and phosphoenolpyruvate in the glycolytic pathway. It had three immunologically distinct subunits α, β and γ, giving rise to the five isoenzymes αα, ββ, γγ, αβ and αγ. In the central nervous system γγ and αγ enolases are mainly localized in neuronal cells, so called neuron-specific enolase (NSE). NSE is released into CSF and serum due to damage of the neurvous tissues.
In this study, we examined NSE levels in CSF of 29 patients and sera of 12 patients with cerebral vascular disease and in CSF and sera of 23 patients with other various neurological diseases.
The present study showed a positive correlation between the size of the infarction or hemorrhage measured on the CT scan and the levels of NSE. More interestingly in acute phase of the patients with mild cerebral ischemic attacks including transient ischemic attack (TIA) and minor stroke, the clue of which was not even visualized on CT scan, the levels of NSE in CSF were also high. Although the neurological deficits depended on the size as well as the site of the infarction, the level of NSE was, however, also related to the clinical outcome in this study. The time sequential changes of NSE levels disclosed more higher levels in acute phase than in subacute or chronic phase, because NSE is rapidly cleared from CSF and serum. On the other hand, in the patients with various other neurological diseases, this study showed some correlation between NSE level and the severity of diseases. Especially, the level of patient with Creutzfeldt-Jakob disease was markedly high in the early stage of the disease at which time the brain CT showed no or minimal abnormalities.
In conclusion, this study demonstrated the positive relationship between NSE levels and the extent of tissue damage of nervous system and suggested that NSE is a potentially important marker of the ultra-early and early diagnosis of ischemic cerebral diseases, especially of TIA.

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An analysis was made on 110 cases of no-direct operation for subarachnoid hemorrhage for comparison with 255 cases of direct operation for subarachnoid hemorrhage. In this study, analysis of the cases was made by incidence, sex, clinical grade on admission, neuroradiological findings, reasons for no-direct operation, outcome at 6 months after initial subarachnoid hemorrhage, cause of death, and long term follow-up results. No-direct operation cases were classified into the following three age groups, that is, Group A less than 60 of age, Group B 60-69 of age, and Group C 70 and over of age, for analysis by the foregoing parameters.
The mean age of the no-direct operation group was 62.9 years and that of the direct operation group was 57.2 years with the age being higher in the no-direct operation group. Clinical grades IV and V accounted for 58% of the no-direct operation group and for 15% of the direct operation group with the clinical conditions being poorer in the no-direct operation group. The subarachnoid clot volume and the incidence of subarachnoid hemorrhage associated with intracerebral hematoma were greater on computerized tomography in the no-direct operation group than in the direct operation group. The most predominant reason for no-direct operation was poor clinical condition on admission, followed by rebleeding and complications. Outcome at 6 months after initial subarachnoid hemorrhage showed a mortality rate of 77% in the no-direct operation group, indicating a very poor prognosis. However, of the 14 cases of no-direct operation due to unknown etiology, 13 cases were able to resume a normal life, showing a favorable prognosis for these cases.

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A case of hydrocephalus due to MDBA is reported. A 66 year-old man complained of dementia and gait disturbances for 6 months. Brain CT revealed hydrocephalus, while cerebral angiography indicated MDBA. Dynamic studies of the CSF presented no abnormality as to passage through the subarachnoid space, absorption and pressure. Hydrocephalus due to MDBA was therefore diagnosed. T₂-weighted MRI demonstrated an elongated basilar artery as low intensity signals due to high-velocity signal loss in the high intensity area of the subarachnoid space, which elevated the basis of the III-rd ventricle resulting in deformity. Furthermore, MRI demonstrated not only the dilated lateral ventricles with the thin corpus callosum, but also the dilated IV-th ventricle and aqueduct. The latter findings suggested that one of the mechanisms of the dilatation process was voluminal changes due to pulse-synchronous translocation of the III-rd ventricular basis rather than a water-hammering effect causing dilatation of the IV-th ventricle and aqueduct.

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The incidence of aneurysmal subarachnoid hemorrhage (SAH) and the outcome of patients with SAH have been previously investigated in Izumo City having a population of 79, 000 and Shimane Prefecture which includes Izumo City and has a population of 790, 000. In the present study, to ascertain the relation of the incidence and the outcome to the size of the geographic area and/or population, we made a similar analysis on an area having a population of 504, 000 which is intermediate in size between Izumo City and Shimane Prefecture. The crude annual incidences of aneurysmal SAH in Izumo City, the intermediate area and Shimane Prefecture were 21.0, 17.6 and 13.9 per 100, 000 population for all ages and the annual operative rates per 100, 000 population were 12.9, 11.1 and 8.9 respectively. The overall mortality rates one year after SAH were 46%, 38% and 35%, respectively. The mortality rates in the three areas were high among unoperated cases.
It is concluded that the smaller the area where the study is conducted, the higher becomes the annual incidence of aneurysmal SAH and the poorer becomes the overall outcome.

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The authors presented seventeen cases with suspected moyamoya disease (unilateral IC lesion) and discussed their clinicopathological features.
The cases with so-called “moyamoya phenomenon” (such as moyamoya vessels associated with occlusive middle cerebral artery, or other systemic disease) were excluded from this study.
These cases were evaluated clinically with CT, angiography and rCBF measurements. Initial symptom, CT findings and collateral circulations verified angiographically revealed same tendency in the definite moyamoya disease (bilateral IC lesion).
Out of 17 cases with suspected moyamoya disease, 11 had angiographically abnormal findings on the non-affected side, which were ICA occlusion in 2, leptomeningeal anastomosis in 5, transdural anastomosis in 4, PCA stenosis in 1, IC aneurysm in 2 and ACA cclusion in 1. One of these 11 cases revealed developing definite moyamoya disease from suspected moyamoya disease by follow up angiography for 4 years interval.
In suspected moyamoya disease, the mean rCBF significantly decreased at the affected site compared with the non-affected site.
These facts suggested that suspected moyamoya disease was not recognized as an another different clinical entity from definite moyamoya disease.

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It is still controversial which type of therapy (conservative or surgical) should be employed for the treatment of patients with hypertensive putaminal hemorrhage.
The purpose of this was to clarify and compare the results of these two therapies. The subjects were 187 patients (116 males and 71 females; 58 ± 13 years old (mean ± SD) who were admitted to Ashikaga Red Cross Hospital during the past 10 years. Brain CT scans were done within 24 hours after admission in all patients. Among them, 159 cases were treated conservatively and 28 were treated surgically. The prognosis of the patients compared on the basis of neurological gradings on admission, mode of extension on brain CT and hematoma size.
Neurological gradings were as follows : 1) alert or confused; 2) somnolent; 3) stuporous; 4a) semicomatose without herniation signs; 4b) semicomatose with herniation signs; 5) deep coma. The mode of extension of hematoma was as follows : 1) extra-capsular (localized); II) Ca (extended to the anterior limb); IIIa) Cp without V (extended to the posterior limbs without massive ventricular hemorrhage; IIIb) Cp with V; IVa) Ca + p without V (extended to the anterior and posterior limbs without massive ventricular hemorrhage; IVb) Ca + p with V; V) Th (extended to the thalamus or subthalamus). Hematoma size was regarded as the largest diameter of the hematoma on brain CT. Prognosis was divided into 6 gradings : 1).full work without disability; 2) full work with minimal disability; 3) partial disability; 4) total disability; 5) vegetative state; 6) dead. Neurological gradings, mode of extension on brain CT and prognosis were classified according to the criteria of the Japanese Conference on Surgery for Cerebral Stroke.
The results were as follows :
1) There was no stastistically significant difference in mortality rate or functional prognosis between the two groups in any neurological grading.
2) The mortality rate of the surgical group tended to be lower in 4b (mode of extention of brain CT) or hematoma size 6-7 cm than that of the conservative group. The above results suggested that operation should be considered from the point of view of mortality rate in selected patients with putaminal hemorrhage.

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For the purpose of evaluating the role of platelet function in the pathogenesis of the cerebral vasospams (VS), time sequential changes of platelet function in blood sampled at three different sites were comparatively examined in 13 patietns with ruptured cerebral aneurysm admitted within 48 hours of the onset. Blood was sampled from the internal jugular vein (JV) and the peripheral vein (PV) every 3 days from the day of admission for about 2 weeks, to examine platelet aggregability, β-thromboglobulin (βTG), and thromboxane B2 (TXB2). In some cases blood was also sampled from the superior sagittal sinus (SSS) during surgery for similar examinations.
The results were as follows : 1) Differences of mesured values in three examinations were less between JV and SSS blood samples than between PV and SSS blood samples. When the time sequential changes of platelet functions were compared between JV and PV blood samples in patients presented 2 or more consecutively high values, JV blood samples showed much higher values than PV blood samples during the period with promoted platelet function. Therefore, the blood sampled from the closer site to the brain may reflects the closer intracranial condition. 2) Platelet function in blood samples from JV tended to have been enhanced during Day 0-1, but it recovered to the normal range during Day 2-4. After the Day 5, its course showed various patterns depending on the clinical course, and was particularly influenced by the symptomatic VS. In patients without symptomatic VS, time sequential changes were relatively minor with normal or a little high values. Patients with symptomatic VS showed high platelet aggregability alredy in the early stage of VS. The values of β-TG increased several days after the onset of VS, and reached to 90 ng/ml or more in patients with poor prognosis. Sequential changes of the TXB2 values were not always consistent. These results may suggest that the VS activates platelets and promotes its aggregation, and that increasing tendency of thrombus formation may affect the patient's prognosis in the advanced stage.

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We examined the csf/serum ratios for albumin and IgG in the elderly patients with chronic cerebral infarction to know the rule of the blood-brain barrier function in the progressive subcortical vascular encephalopathy (PSVE).
17 patients with PSVE, 9 patients with cerebral infarct in the territory of cortical arteries, and 5 controls were examined.
Patients with PSVE showed significantly (p<0.05) elevated csf/serum ratios for albumin and IgG compared to them of the other groups.
However, there was no significant difference in csf/serum ratios for albumin and IgG between the group of patients with cerebral cortical infarct and the group of controls.
There was also no significant difference in IgG index among 3 groups.
These results showed that there was an increase of the permeability of the cerebral blood vessels in PSVE..
We need to consider that they could have some rule on a genesis of the brain damage in PSVE.

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The clinical results of hypervolemia/hypertension therapy for cerebral vasopasm were studied in patients with ruptured intracranial aneurysm. Patients with brain damage due to old stroke, intracerebral hematoma and surgical complications were excluded. Case materials consisted of 111 patients, who were hospitalized between 1982 and 1985. 55 males and 56 females; 55 ± 10 years old. Neck clipping of ruptured aneurysm and continuous ventricular drainage were carried out within three days after onset. Sixty seven patients were treated with hypervolemia/hypertension therapy postoperatively. Forty four patients were not treated with any intention therapy for cerebral vasospasm except of low molecular dextran (500 ml/day). Hypervolemia therapy was carried out by albumine (100 ml/day) and human plasma (200 g/day) to maintain a central venous pressure of 7 to 10 cmH₂0. And, dopamine- or dobutamine-induced hypertension therapy was applied for patients with severe subarachnoid hemorrhage, symptomatic vasospasm and/or severe angiographical vasospasm. Dopamine or dobutamine was given at a rate of 5 to 10 μg/kg/min. to maintain a systolic blood pressure of 150 to 160 mmHg. The method of those therapy was not so intensive to compare with previous reports.
To compare with the results of patients without hypervolemia/hypertension therapy, the incidence of symptomatic vasospasm was significantly decreased in patients with the therapy. In patients with postoperative general complications, it was difficult to maintain the appropriate intravascular volume. To study patients without postoperative general complications, the degree of symptoms due to cerebral vasospasm was significantly mild in patients with the therapy. However, the efficacy of the therapy to improve symptoms due to cerebral vasospasm was not confirmed in this study.
Thus, a more intensive method of the therapy under monitoring intracranial and cardiovascular parameters will be necessary to get more effective results.

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Two autopsy cases of basilar artery fenestration are reported concerning the pathogenesis of the fenestration and related aneurysms. One patient was a 78-year-old woman who died of cerebral infarction, and an unruptured aneurysm associated with a fenestration of the proximal third of the basialr artery was obtained at her autopsy. The aneurysm arose from the proximal end of the fenestration and projected ventrally and superiorly. Serial sections were obtained proceeding from the vertebral arteries to the normal basilar artery distal to the fenestration. Histologically, defects of the media and internal elastic lamina with gradually thickened intima were noted at the orifice of the aneurysm, which was not unusual for an aneurysm at arterial bifurcation. This was the first reported case of an unruptured aneurysm in the basilar artery fenestration.
The other patient was a 67-year-old man who died of massive ventricular hemorrhage, and a fenestration of the proximal third of the basilar artery without an attendant aneurysm was found at his autopsy. Longitudinal sections including the proximal and the distal end of the fenestration were obtained. Histological study of the area where the united vertebral artery bifurcates revealed thinning of the muscular coat and its actual absence for about 40μ. The internal elastic lamina was intact and directly attached to the adventitia. Study of the area where the branches reunited showed a short segment of medial defect, and the intima overlying this area was thickened. These findings demonstrated that where fusion of the embryonic longitudinal neural arteries stops, a structural defect exists.
44 cases of aneurysms associated with basilar artery fenestration have been reported in the literature. In 43 cases, the aneurysms occured at the proximal end of the duplicated segment. But a case of the aneurysm distal to a fenestration of the terminal basilar artery was reported by Andrews et al. in 1986. Defect of the media at the junctions of the fenestrated segments, as well as the possible presence of turbulent flow at the vertebro-basilar junction, may explain the high incidence of the proximal-end-aneurysms of the fenestration.

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