We investigated the pathogenesis of the thrombotic stroke in the young with assay for coagulation and fibrinolytic factors in plasma.
Eleven thrombotic stroke patients under 39 years old, 30.0±7.9 years old (mean±2SD), who had no risk factors such as hypertension, hyperlipidemia, collagen disease, and cardiac disease were reviewed. These consisted of ten males and one female, 31.7±5.3 years old (mean±2SD) for the control. The group of patient was clasified by computed tomography into two types; (1) small infarction, so called deep branch artery occlusion, four cases and (2) massive infarction, so called cortical branch artery oclusion, seven cases. Cerebral angiography was studied in six cases of massive infarction. Among of the six cases, two cases were right carotid artery occlusion, two cases were left carotid artery occlusion, one case was left posterior cerebral artery occlusion and one had no evidence of occlusion.
We investivated the coagulation and fibrinolytic system with assay for Hageman factor, Factor VIII, C1 estelase inhibitor, antithrombin III (AT III), plasminogen, α₂ plasmin inhibitor, Factor VIII related antigen (VIIIR : Ag), von Willebrand factor activity (vWF) and fibronectin. We could not find out any abnormalities except one case in which has congenital AT III deficiency. In this case, we suspected that the thrombotic stroke was induced by inadequate regulation of coagulation. vWF and VIIIR : Ag which have been throught as the marker of vascular damage were significantly higher in the patients with cortical branch artery occlusion than that in the patients with deep branch artery occlusion (0.005<p<0.01). According to the above data, although the young, cortical artery occlusion may be attributed to systemic vascular damage even in the young adults. And we could find out the teatable factor such as AT III deficiency in the young patients with thrombotic stroke.

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Serum lipoproteins, apolipoproteins and lecithine : cholesterol acyltrasferase (LCAT) activity were determined in 103-patients of cerebral infarction and 88-patients of cerebral hemorrhage, more than three months after the attack. Serum total cholesterol and low density lipoprotein (LDL) cholesterol values were significantly higher in cerebral infarction than in cerebral hemorrhage and in control patients without cerebrovascular accidents. On the other hand, no difference was observed in serum high density lipoprotein (HDL) cholesterol and triglyceride values among three groups. Apolipoprotein A-I/A-II ratio was significantly lower, while apolipoprotein E and LDL-cholesterol/apolipoprotein B ratio were significantly higher in cerebral infarction than in others. LCAT activity tended to be higher in the patients with cerebrovascular diseases than in controls. In conclusion, these results demonstrated the abnormalities of serum lipoprotein metabolism in chronic phase of cerebral infarction.

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We have experienced 53 cases with multiple aneurysms during the past 6 years and 6 months. The incidence of multiple aneurysms was 17.6% in our series. The locations with the highest probability of rupture were anterior cerebral artery (70%) and anterior communicating artery (68%). It was possible to identify which aneurysm had ruptured in 92% of the cases preoperatively. Both ruptured and non-ruptured aneurysms should be treated in a early one staged operation, except for a few cases, such as those with aneurysms, one of which was located at the posterior circulation or those with poor-risk. In our series, however, the results of early one staged operation was poor with a mortality rate of 28%. Three patients died due to the postoperative intracerebral hematoma caused by disturbance of the venous return. All 3 patients were operated by the pterional and ipsilateral interhemispheric approaches for the accompanying distal anterior cerebral artery aneurysm. Therefore, in the cases of multiple aneurysms accompanied by distal anterior cerebral aneurysm, it should be emphasized to preserve the venous circulation.

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A 62-year-old man with Subclavian Steal Syndrome was treated by percutaneous transluminal angioplasty (PTA) of the left subclasvian artery, and the blood flow of the left vertebral artery was also measured by doppler sonogram transcutaneously during manipulation of PTA. On examination, asymmentry of blood pressure in bilateral upper extremity and arterial bruit on the left supraclavicular fossa was confirmed.
Doppler sonogram of the left vertebral artery showed retrograde blood flow from the distal to the proximal side of the artery. Aortography demonstrated stenosis of the junction of the left subclavian artery more than 90% in width and 1.8 cm in length. PTA was performed by using Olbert Baloon Catheter of which size is 6 mm in diameter and 4.0 cm in length.
After first trial of PTA by 2 minutes inflation of the baloon at a pressure of 6 atomosphere (atm), blood flow showed almost silent flow first, then the type of To and Fro flow. Approximately 220 seconds later, antegrade but low flow of the left vertebral artery was confirmed on the doppler sonogram, but 80 seconds later blood flow returned to retrograde flow.
At the second trial of PTA by increasing the pressure from 6 atm to 8 atm, the retrograde flow changed to antegrade flow immediately after deflation of the balloon, so did the flow of the left vertebral artery at the third trial of PTA at a pressure of 10 atm.
These findings may indicate that the more PTA repeats the higher the possibility of cerebral embolism.

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We examined the relationship between occurrence of consciosness disturbance and laterality of cerebral lesions in 144 acute putaminal hemorrhages, 127 acute thalamic hemorrhages and 35 acute cortical hemorrhages. Result were as follows : 1) there are no significant differences in size of hematomas between the left and the right cerebral hemispheres in all groups. 2) in putaminal hemorrhages, the grade of consciousness disturbance was mostly moderate, while in thalamic and cortical hemorrhage, consciousness disturbance was rather slight. 3) there was a tendency that moderate or severe disturbances of consciousness occured in left hemispheric lesions in all groups, although no statistical signifficance was obtained. 4) No confirmatory relationship could be found between level of consciousness disturbance and laterality of cerebral lesion in all group even though the size of hematomas was divided into two subgroups (more than the mean size and less than the mean size). 5) In case of previous cerebrovascular history, such a tendency as moderate or severe disturbance of consciousness was more frequent in left hemispheric lesions was observed, but with no statistical significance.

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A 76-year-old woman was admitted to our hospital because of repeated transient ischemic attacks (TIAs). Physical examinations showed hypertension and hepatosplenomegaly. Neurological examination revealed right hand pronation sign, right everted foot and slight right hemisensory disturbance.
Peripheral blood showed as follows : RBC 6.53×10⁶/mm³, Hb 18.2 g/dl, Ht 56.0%, WBC 10500/mm³ and platelets 81.3×10⁴/mm³. Bone marrow examination showed hyperplasia involving all three marrow elements. Total red cell volume measured by the ⁵¹Cr method, was 63 ml/kg body weight. Serum vitamin B₁₂ was 3590 pg/ml and unsaturated B₁₂ binding capacity was 2559 pg/ml. Arterial oxygen saturation was 94.6%. High blood viscosity and platelet hyperaggregability were observed.
CT scan of the brain showed periventricular lucency. Magnetic resonance imaging (MRI) using T₂ weighted spine echo image demonstrated multiple high intensity areas located in basal ganglia and near the lateral ventricles. Positron emission tomography (PET) showed decreasement of regional cerebral blood flow and regional cerebral metabolic rate of O₂ in sites from left frontal lobe to left temporal lobe. Left carotid angiography showed a severe stenosis of M₁ portion.
On the basis of the findings, the diagnosis of polycythemia vera with TIAs was made. Although she was treated with ticlopidine, venesection or warfarin, TIAs occured repeatedly. Busulfan (2-4 mg/day given orally) and aspirin administration were effective to prevent TIAs. Therefore, the severe stenosis of M₁ portion of left carotid artery and platelet hyperaggregability contributed to TIAs in this case.

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The authors report a rare operated case of spontaneous disappearance of an arteriovenous malformation (AVM) confirmed by the second angiogram performed 14 years after the initial hemorrhage.
This 45 years-old man had a sudden attack of severe headache, speech disturbance and left hemiparesis in February 1967 and was diagnosed as intracerebral hematoma. He had been suffered from uncontrollable seizure and was admitted to Chugoku Rousai Hospital in September 1971. The right carotid angiogram on admission showed a medium size (5.5×5.0×4.0 cm) of AVM in right temporal region supplied by posterior temporal artery. He had been treated conservatively. Uncontrollable seizures and consciousness loss attacks had been continued in spite of anticonvulsants therapy. Finally he reffered to our hospital again in April 1985. However, the right caortid angiogram did not recognize AVM. CT-scan revealed a heterogenious high density area in the right frontotemporal region and enlarged lateral ventricles. Because of the uncontrollable seizure, the total removal of the AVM was performed. At the operation, white thrombosed vessels and porencephalus were disclosed at the right Sylvian fissure. The thrombosed vessels were totally removed. Pathological examination revealed the thrombosed AVM. After the operation, no seizure attack had been observed.

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A case of acute hydrocephalus in the aged patient is reported to show the fragility of the aged brain against the increased intracranial pressure.
A 76-year-old woman was admitted to our hospital because of slight right hemiparesis and stuporous state. CT scan taken 2 hours after the onset demonstrated hemorrhage in the head of left caudate nucleus and its ventricular rupture. She was treated conservatively but the next day, she suddenly fell into coma and had respiratory arrest. Soon after resuscitation spontaneous respiration was restored and about 2 hours later she began to recover consciousness. CT scan showed slight enlargement of the lateral and third ventricles. The continuous ventricular drainage improved her consciousness from stupor to confusion. On the 4th postoperative day, the draining pressure was increased from 100 mmH₂O to 120 mmH₂O but this caused consciousness disturbance and she became stuporous. Therefore lumbo-peritoneal shunting was performed using a tube with low pressure slit valve (opening pressure of 50 mmH₂O) and afterwards she recovered again.
It appears that a slight increase in the intracranial pressure with minimal changes of the ventricular size can cause consciousness disturbance in aged acute hydrocephalic patients.

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Evidence has been accumulated that patients with acute cerebrovascular diseases (CVD) are attended with disturbances of autonomic nervous functions. The response of plasma arginine vasopressin (AVP) to postural change had been regarded as an index of the function in the autonomic afferent division from baroreceptors and volume recepotrs. The present study was designed to investigate the autonomic afferent nervous function in the patients with acute CVD.
The test of 70° passive head-up tilting for 15 minutes was performed on 27 patients (64±11 y.o.; mean±S.D. with acute (5.0±5.9 days after the onset) CVD [10 with intracerebral hemorrhages (ICH), 17 with cerebral infarctions (CI)] and 13 age-matched healthy volunteers as controls. The blood was sampled before and during head-up tilting in order to measure plasma AVP and norepinephrine (NE).
[1] Supine position : The plasma AVP significantly increased in both ICH and CI as compared to the controls (p<0.05, p<0.05, respectively). It tended to be higher in the group with ICH than in the group with CI (p<0.1). There was a positive correlation between plasma level of AVP and NE (p<0.05). [2] Head-up position : 1) The significantly greater rise in AVP (ΔAVP) to postural change was observed in ICH as compared to CI and the controls (p<0.01, p<0.01). 2) The increase in NE tended to be greater in ICH than in IC or in the controls (p<0.1).
This study provides strong evidence that exaggerated responses occur not only in the efferent division but in the afferent division of the autonomic reflex arch in the acute intracerebral hemorrhage.

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We have reported previously that red blood cell aggregability (RBC-A) is enhanced in patients with occlusive cerebrovascular disease. The purpose of the present study was to compare RBC-A between deep subcortical infarction and cortical infarction. The subjects comprised 77 patients (54 males and 23 females, 59±9 YO) at the chronic phase (more than 1 month after onset) of occlusive cerebrovascular disease and 38 healthy human volunteers (N=38, 59±9 YO). the patients were divided into three groups according to their brain CT findings; Group 1, deep subcortical infarction, N=46, 61±9 YO, Group 2, cortical infarction, N=21, 55±10 YO : and Group 3, deep + cortical infarction, N=10, 58±6 YO. RBC-A was measured using the whole blood RBC aggregometer developed by us (Am J Physiol 251 : H1205-H1210, 1986) with concomitant measurement of the hematocrit, albumin-globulin ratio (A/G ratio) and fibrinogen. The RBC-A values in groups 1, 2 and 3 were 0.151±0.026/s, 0.137±0.024/s, and 0.161±0.026/s, respectively. These values were statistically significantly (p<0.01, p<0.05, p<0.05) higher than that of the control group (0.123±0.021/s). There was a statistically significant difference (p<0.05) in RBC-A between group 1 and group 2. Although the values of the hematocrit and A/G ratio did not differ in each group, there was a tendency for the fibrinogen level to be higher in group 1 (322±78 mg/dl) as compared to group 2 (295±41 mg/dl). It is suggested that deep subcortical infarction was more closely related to hemorheological abnormality than was cortical infarction.

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The risk factors affecting rebleeding from the ruptured cerebal aneurysms were analyzed in 28 patients who all had rebleeding and treated at Ohmuta City Hospital from 1983 to 1986. The series included 14 men and 14 females with age ranged from 29 to 85 years (mean age of 58.3 years). Based on the time period from the initial attack of subarachnoid hemorrhage to rebleeding, the patients were divided into two groups as within 12 hours (early) and over (delayed) for comparison. The rebleeding was most frequently seen within 3 hours follwing the first attack. But there was no significant difference in the age, sex, site of ruptured aneurysm between the two groups. Neurological deterioration following rebleeding and frequency of rebleeding were more significant in patients with early rebleeding than in patients with delayed rebleeding and the mortality rate in the former group was 71.4%. The incidence of associated hypertention was also significantly high as 71.4% in the former group. From these results, an intensive care for blood pressure control and early operation are recommended for the patients with ruptured cerebral aneurysm in the acute stage.

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There have been only 23 cases with distal anterior inferior cerebellar artery (AICA) aneurysm in the literature. Since these aneurysms usually arise from the junction of the meatal loop with the internal auditory artery (IAA), the seventh or eighth cranial nerves are frequently involved. We reported the case of the distal AICA aneurysm who did not show the disturbances of these cranial nerves before and after the operation.
A 38-year-old female was admitted to our clinic with complaining of sudden onset of headache and vomiting. CT scans showed subarachnoid hemorrhage (SAH). Bilateral retrograde brachial angiography and left carotid angiography on admission did not show any cause of hemorrhage. Repeat angiography through a Seldinger's procedure performed on the 15 days after SAH revealed an aneurysm of distal AICA. By the right suboccipital craniectomy on the 22 days after SAH, the aneurysm arising from the distal branch of the meatal loop of AICA was found on the eighth cranial nerve with its funds pointing superomedially, and adherent to the cerebellum. The neck of the aneurysm was successfully clipped. The patient's postoperative course was uneventful.
It should be emphasized that 4-vessel angiography by Seldinger's procedure is a preferred procedure in the case when the vertebro-basilar aneurysm is suspected.

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The present study was aimed to assess the reproducibility of blood flow velocity measurement in the middle cerebral artery by transcranial real-time color-flow Doppler ultrasonography (TRCD).
In 42 middle cerebral arteries of 21 healthy volunteers (age ranged from 22 to 41 years old), TRCD was performed by two examiners with an interval of seven days or less.
The angle (θ) between the pulsed Doppler beam and the blood column in horizontal portion of the middle cerebral artery, which was clearly visible on the CRT, was measured in parallel with the mean velocity. The absolute flow velocity was calculated by dividing the measured flow velocity with cos θ. The reproducibility of mean flow velocity was excellent when the correction with incident angle was made. The correlation coefficients between flow velocities obtained by two examiners were 0.93 and 0.66 with and without correction using the incident angle, showing much better reproducibility in the former.
This fact suggested that the correction of flow velocity by the incident angle is necessary to obtain the accurate and reproducible flow velocity of the middle cerebral artery. TRCD is an useful method with excellent reproducibility in measurement of middle cerebral arterial blood flow velocity, since measured velocity can be corrected with the incident angle.

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