The purpose of the present study was to evaluate the correlation between regional cerebral blood low (rCBF) and unilateral spatial neglect (USN), one of the common signs of higher nervous function disturbance. We measured rCBF using ^99mTc-ethyl cysteinate dirner (^99mTc-ECD) SPECT and analyzed the data quantitatively by the Patlak plot method in 69 sujects with chronic-stage cerebrovascular disease. All of them were right-handed and were damaged on their right cerebral hemisphere. We evaluated the correlation between (1) rCBF and USN, (2) %reduction of CBF (%Re) and USN and (3) rCBF and%Re. USN was checked by employing the line bisection and the star cancellation test. The USN positive group revealed a significantly de-creased rCBF and higher % Re in the right parietal region when compared to the USN negative group. When divided at rCBF values of less than 21.6 (ml /100 ml /min) and % Re values of more than 31.2 (%) in the right parietal region, the USN positive group and USN negative group could be clearly separated. In the majority of patients with thalamic hemorrhage, a decreased rCBF in the right parietal region appeared with USN. These results indicated that a decreased rCBF in the right parietal region was cross-correlated with the existence of USN with and without lesion. In conclusion, the appearance of higher nervous function disturbance could be detected by measuring rCBF by clinically available SPECT studies.

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The frequency of occurrence of stroke at different seasons or on different days of the week was investi-gated in 794 patients with stroke who were admitted to our hospital between December 1991 and November 1996. They included 291 patients with brain hemorrhage and 503 with brain infarction. The brain infarction was classified according to criteria based on the clinical findings into atherothrombotic stroke (n=196), lacunar stroke (n=158), and cardioembolic stroke (n=149) . Careful histories were taken from the patient or a person who observed the onset to determine the day of the week on which the onset of stroke occurred. For atherothrombotic stroke, the incidence of stroke was high on Fridays, but low on Saturdays and Sundays (chi-square test for goodness of fit, p<0.02), particularly in working men younger than 65 years (p<0.1). For other types of stroke, there was no specific day of the week on which stroke was likely to occur. Winter was the peak season for brain hemorrhage (p<0.05). Seasonality was found in the older age group for lacunar stroke (p<0.1) and in the younger age group for brain hemorrhage (p<0.1) . These findings support the hypothesis that the onset of all types of stroke may be triggered by life circumstances, life cycle and changes of weather.

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We investigated the structural changes of the corpus callosum in patients with Binswanger's disease (BD) employing the magnetization transfer (MT) imaging technique. Patients with BD revealed significant decreases in the areas of the anterior and posterior portions of the corpus callosum. The MT ratios were significantly lower in the middle portion of the corpus callosum without definite atrophy, as well as in the anterior and posterior portions, in patients with BD when compared to the controls. Significant correlations ex-isted between the MT ratio in the periventricular white matter lesions and area of the corpus callosum, and between the HDS-R score and MT ratio and area in the anterior portion of the corpus callosum. These find-ings probably reflected structural changes in the corpus callosum including axonal loss and/or demyelination, resulting from white matter damage. Moreover, the structural changes in the anterior portion of the corpus callosum associated with frontal white matter damage may reflect the severity of cognitive impairment.

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[in Japanese]

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The clinical findings of headache asstociated with brain stem infarction were evaluated in 53 cases including, 28 with pontine infarction and 25 with medullary infarction. Headache occurred in 17 patients (31%), including 5 with pontine infarction (18%) and 12 with medullary infarction (48%). It was significantly more common in medullary infarction than in pontine infarction (p<0.05). The headache was bioccipital and mild in all of the 5 cases with pontine infarction. In contrast, it was lateralized at the ipsilateral side of the lesion in all of the 12 cases with medullary infarction: 8 cases (66%) had headache in the frontal lobe and 6 cases (50%) in the occipital lobe. Among the 12 cases of medullary infarction, the headache was severe in 4, moderate in 4, and mild in the remaining 4 cases. Headache preceded the onset of stroke by 2 to 14 days in 4 (33%) of the 12 patients with medullary infarction. Angiography revealed a dissecting aneurysm of the posterior inferior cerebellar artery (PICA) in one patient with medullary infarction. It is suggested that the mechanism of headache in medullary infarction differed from that in pontine infarction. We infer that headache with medullary infarction may be caused mainly by a dissecting aneurysm of the vertebral artery or PICA.

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We report an autopsy case of multiple paradoxical embolism after urological surgery. A 50 year-old woman who had a history of varicose veins of the leg lost consciousness and suffered dyspnea following bed rest for 20 hours after surgery. She was admitted to our hospital with coma, respiratory failure and hemiparesis on the left side. A pulmonary perfusion scan revealed multiple perfusion defects in the bilateral peripheral lung fields although a transthoracic echocardiogram lacked evidence of right atrium overload or intraluminal thrombus. A head CT scan on day 3 demonstrated large low density areas in the bilateral middle cerebral artery territories. She died on day 7 due to uncal herniation. An autopsy study disclosed a patent foramen ovale in the artial septum, large thrombus in the inferior vena cava, left pulmonary infarct, and massive and multiple brain infarct. This is a significant case of multiple paradoxical embolism following urological surgery confirmed by autopsy.

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We report a case of cervical carotid dissection in which cerebral angiography revealed stenosis, occlusion, and spontaneous resolution over time. A 56-year-old man admitted to our hospital with transient ischemic attack suffered right hemiplegia and aphasia. Left cerebral angiography conducted on the following day showed an irregularity in the wall of the cervical internal carotid artery. Cerebral angiography one week later dis-closed an occlusion in the left cervical internal carotid artery. Right cerebral angiography demonstrated bypass blood flow through the anterior communicating artery, but no difference was observed between the left and right hemispheres on single-photon emission computed tomography (SPECT). Conservative therapy was therefore carried out. Nineteen months later, the left internal carotid artery was evident on MRA. Left cerebral angiography revealed only a notable meandering in the cervical internal carotid artery, where the irregularity in the wall had been observed at initial cerebral angiography-a result which indicated complete resolution. Time-course observation is considered necessary because spontaneous resolution can occur even after occlusion in some patients with carotid dissection.

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We encountered a case of peripheral posterior inferior cerebellar artery aneurysm. A 79-year-old female was admitted to our institute because of sudden onset of severe headache. An examination (angiography) revealed a succular aneurysm of the right vertebral artery which terminated at the right posterior inferior cere-bellar artery. The ruptured aneurysm at the corner between the lateral medullary segment and posterior medullary segment of the posterior inferior cerebellar artery was successfully clipped ; however, there was no branch take-off at around the origin of the aneurysm. Previously another unruptured aneurysm had been noted at the right internal carotid terminus as a multiple aneurysm. From these findings, it is suggested that congenital factors could have been as important in the etiology (pathogenesis) of the aneurysm as an increase in hemodynamic stress. We discuss this problem together with other reported cases.

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Simultaneously multiple intracerebral hemorrhage is very rare. We report an 80-year-old hypertensive man with multiple intracerebral hemorrhage occurring simultaneously in the supra-and infratenorial regions. At admission, he displayed consciousness disturbance and left hemiparesis. His blood pressure was over 300/ 150 mmHg. Laboratory examinations revealed a low cholesterol value (115 mg/ml). Brain CT scans were per-formed within one hour after the onset. They showed right putaminal, thalamic, and night cerebellar hemorrhage. Brain MRI revealed three hematomas that were independently isolated and sxihibited the same aging pattern. It appeared that these hemorrhages had occurred simultaneously on one side of the supra-and infrat-entorial brain. No causative factors such as vascular angitis were identified.
A retrospective analysis was performed on 104 consecutive patients with hypertensive intracerebral hemorrhage at our hospital during a one-year period in 1997.
The hemorrhage sites and frequencies were as follows : putamen (45.2%). thalamus (25.0%), brain stem (10.6%), subcortical region (8.6%) and cerebellar region (7.7%). Hypertensive hemorthage of the subcorti-cal and cerebellar regions occurred most frequently in elderly patients as compared to otherregions. Simultaneously multiple intracerebral hemorrhage was encountered in 3 patients (2.9%). All of them except the present patient showed a combination of the putamen and thalamus. We reviewed 22 patients with simultaneous multiple intracerebral hemorrhage occuring in the supra-and infratentorial regions in the Japanese literature with respect to their clinical characteristics pathogenesis of multiple hematomas and prognosis. Our case is the first reported patient involving three simultaneously hemorrhagic sites.

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We report a patient with severe orthostatic hypotension, who was successfully treated with enalapril. A 78-year-old man with a history of hypertension and lacunar brain infarctions was admined to our clinic. He could hardly stand up since an upright posture resulted in severe dizziness. Physical examinations revealed orthostatic hypotension and peripheral sensory and motor neuropathy. His blood pressure dropped from 180/ 92 mmHg to 102/66 mmHg on standing, with no change in heart rate. Deposion of AA amyloid was confirmed by duodenal biopsy. The cerebral hemodynamic changes were studied during passive tilting up of the body. The followìng parameters were recorded : mean blood pressure (MBP), heart rate (HR), end tidal CO₂, and mean blood flow velocity (MFV) of the middle cerebral artery trunk as measured by transcranial Doppler sonography. The lower limit of cerebral blood flow autoregulation shifted from 95 mmHg to 80 mmHg in terms of MBP, after a 14-day course of treatment with enalapril (0.625 mg/day, p. o.). Use of elastic stockings increased the upright MBP from 78 mmHg to 83 mmHg. The upright MBP thus became higher than the lower limit of cerebral blood flow autoregulation, and the orthostatic dizziness improved. ACE inhibitor may be useful for the treatment of hypertensive patients with orthostatic hypotension, by improving abnormal shifts in the lower limit of cerebral blood flow autoregulation.

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A 69-year-old and right-handed man suddenly suffered from sensory sphasia An occlusion of the horizontal segment of the left middle cerebral artery (MCA) was revealed by intra-arterial digital subtraction angiography (IA-DSA) on day 1. This patient was diagnosed as having atherothrombotic brain infarction. After he had been administered argatroban intravenously, his sensory aphasia was converted to motor aphasia and he became clearly right hemiparetic including his face on day 2. On day 8, MR angiography demonstrated relatively good running off from his left MCA On day 21, IA-DSA was performed again and recanalization of the horizontal segment of the left MCA accompanied by 90% residual stenosis was observed. The cortical infarction in this case was estimated to be an artery-to-artery embolism due to thrombi which had formed at the stenotic MCA lesion. It is suggested that in some cases of atherothrombotic brain infarction, antithrombotic therapy can produce recanalization and artery-to-artery embolism.

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