To elucidate the pathogenesis of stroke, 26 hypertensive patients complicated by high hematcrit levels more than 45% were studied. All of the patients examined were male and middle to old aged. Ruddy cyanosis and slight overweight were observed in most cases. Hematocrit value was 48.9% in average and was over 50% in 11 cases. Either white blood cell counts or platelet counts were within normal limits. Splenomegaly was found of moderate degree in one and of slight degree in 4 cases. If the patient with moderate splenomegaly was excluded from the study group, it was not probable that any patients had been suffering from polycythemia vera. The mean value of plasma renin activity was normal. The serum levels of total cholesterol, triglyceride and uric acid were significantly higher and the serum level of HDL-cholesterol was significantly lower than those in controls.
Stroke was found in 16 out of 26 patients. Cerebral infarction in the distribution of perforating cerebral artery was most frequently encountered. Hence, it was strongly suggested that hypertensive patients complicated by erythrocytosis had a high incidence of stroke, even though erythrocytosis was determined to be present, when hematocrit values were over 45% in the present study. Furthermore, hypertensive patients with erythrocytosis were frequently complicated by many risk factors for stroke such as hypercholesterolemia, hypertriglyceridemia, hypoalphalipoproteinemia and hyperuricemia. Therefore, these risk factors should be carefully checked and treated.

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Platelet cyclic nucleotides (c-AMP, c-GMP) play an important role in platelet aggregation. It is reported that the elevation of c-AMP suppresses platelet aggregation by inhibition of Ca²⁺ transport from the Ca²⁺ storage site in the platelets. Although the role of platelet c-GMP is still obscure, it may be closely associated with platelet aggregation.
Incidence of cerebrovascular diseases (CVD) are closely related to arteriosclerosis which occurs from hypertension, diabetes mellitus and hyperlipemia etc.. Also arteriosclerosis has intimate correlation with platelet aggregability through the metabolism of arachidonic acid in platelets and arterial walls.
In this study, the platelet cyclic nucleotide levels were investigated in 28 age matched healthy controls, 31 patients with cerebral thrombosis, 18 patients with cerebral hemorrhage and 25 patients with diabetes mellitus.
The CVD stages were divided into acute and chronic stages. The acute individuals were within 10 days from the attack, while the chronic individuals were 21 days to 3 months after onset of the diseases.
Peripheral venous blood was collected into the tube containing sodium citrate (blood : sodium citrate=9 : 1) and the platelet rich plasma (PRP) was prepared by centrifugation. After adding 6% trichloroacetic acid to the PRP, it was centrifuged and the supernatant was used for the cyclic nucleotide assay. The cyclic nucleotides (c-AMP, c-GMP) were measured by radioimmunoassay.
The platelet count and the cyclic nucleotide values of the PRP were in linear correlation. Therefore, cyclic nucleotide concentration was expressed as p moles/1 × 10⁸ platelets/ml.
Platelet c-AMP levels were elevated in the acute stage of cerebral hemorrhage compared with platelet c-AMP levels of the chronic stage in individuals. But there were no significant differences of platelet c-AMP levels between the acute stage of cerebral thrombosis and the chronic stage. While platelet c-AMP levels were low statistically in the chronic stage of cerebral thrombosis, cerebral hemorrhage and in diabetes mellitus compared with the healthy adult controls.
Platelet c-GMP levels were higher in the acute and in the chronic stage of cerebral thrombosis and hemorrhage compared with the age matched healthy controls. There was a tendency of an elevation of platelet c-GMP levels in the acute stage of CVD compared with platelet c-GMP levels in the chronic stage. On the other hand, there were no significant differences of platelet c-GMP levels in the diabetic patients.
c-AMP/c-GMP ratio was low in the acute and in the chronic stage of cerebral thrombosis. This ratio was also low in the chronic stage of cerebral hemorrhage, while there was no statistical difference in the ratio between diabetes mellitus and the healthy controls.
It is shown that platelet c-AMP and c-GMP levels have a close relationship to arteriosclerotic diseases (cerebral thrombosis, cerebral hemorrhage, diabetes mellitus).

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A case of right thalamic hemorrhage with aphasia and conscious hemiasomatognosia is reported.
A 77-year-old right handed woman had no left handed prediposition. She presented acute onset of left hemiplegia and consciousness disturbance; she was admitted to the hospital. We observed mild consciousness disturbance, left homonymous hemianopsia, upward gaze palsy and conscious hemiasomatognosia of left extremities. A CT-scan revealed right thalamic hemorrhage with rupture into right lateral ventricle. The Standard Language Tests of Aphasia (SLTA) which were performed 20 days after onset revealed total aphasia with perseveration, fatigability, paucity of spontaneous speech and small vocal volume. The SLTA in 70 days onset revealed moderate improvement.
Some papers concerning thalamic aphasia or crossed aphasia have been reported. However only a few papers regarding aphasia after right thalamic hemorrhage are reported. These patients are all left handed. We reporte a case of crossed aphasia in a right handed patient after right thalamic hemorrhage for the first time.

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The small infarctions developped in the white matter (corona radiata) lateral to the middle of caudate body were analized. We collected 17 such cases, aged 44-75 years old. In many cases the sizes of the lesion were not larger than 20 mm in diameter on CT scan, and the area was just spreaded to the top of putamen. In summary their natures are as follows : (1) It takes much time from the onset to the completion of the symptoms. (2) As a risk factor, hypertension and glucose intolerance are often seen. (3) There are not few cases of infarction which occurred under good control of their hypertension. (4) Hematocrit level is not always high. (5) Clinucal symptom reveals pure motor hemiplegia, more prominent on the upper extremity especially distally. (6) On angiography many cases show prominent arteriosclerosis of carotid siphon, the main trunk of anterior and middle cerebral arteries. The character of the clinical symptom is probably due to the fact that the fibers from the precentral motor area of the upper extremity to the internal capsule go through this area. Other natures will be the ones of terminal or border zone infarction. Probably this area belongs to the border zone of the cortical branches and perforators of middle cerebral artery, or the terminal zone of the perforators of middle cerebral artery.
When take it the other way round, we should consider this type of infarctions when we see the patients who have pure motor hemiplegia conspicuous on the upper extremity especially distally. This knowledge is useful for clinical diagnosis.

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Thirty-one patients were treated by various revascularization procedures, mainly by encephlo-myo-synangiosis. A total of 113 rCBF measurements were performed by a ¹³³Xe inhalation method. Preoperative mCBF values were markedly lower in most of the young patients than in healthy young volunteers, while there is no significant difference between the adult groups. Postoperatively, mCBF increased by an average of 7.1% in the children, while it decreased slightly or remained unchanged in the adults. Postoperative improvement of abnormal distribution of rCBF was demonstrated in approximately two-thirds of the children, as compared with the adults showing little improvement. Pre- and postoperative CO₂ responses were examined in 4 children, and impaired CO₂ response was improved in all the operated hemispheres. Our experience suggests that the surgical treatment can be an effective procedure for preventing the progression of clinical findings caused by cerebral ischemia and for improving the cerebral hemodvnamics, especially in children with moyamova disease.

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Beta-endorphin levels in plasma and cerebrospinal fluid (CSF) were measured in patients with aneurysmal subarachnoid hemorrhage with (Group 3) or without (Group 2) symptomatic spasm. All patients were operated upon on day 0 or 1 after subarachnoid hemorrhage. Patients with cerebral infarction (Group 4) and those with various neurologic disorders with or without craniotomy (Group 1, control) were also studied.
Routine craniotomy itself did not result in any abnormal levels of plasma and CSF beta-endorphin. When compared to Group 1, the postoperative course of beta-endorphin levels did not differ significantly in patients with cerebral aneurysm, either with or without development of symptomatic vasospasm. Similarly, beta-endorphin levels in patients with cerebral infarction failed to show any significant changes.
In summary, plasma and CSF levels of beta-endorphin do not seem to be an useful marker of acute cerebral ischemia.

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A case harboring cavernoma, azygos anterior cerebral artery (azygos ACA) and multiple aneurysms is reported. A 68-year-old female was admitted with subarachnoid hemorrhage (SAH). Neurological examination showed mild confusion, moderately severe headache and severe neck stiffness. CT scan demonstrated SAH which was most prominent in the frontal interhemispheric fissure. Bilateral carotid angiography demonstrated an azygos ACA and two aneurysms, one at the distal end of the azygos ACA and the other in the proximal end of it. Tumor stain, early venous filling, or dilated abnormal vessels were not demonstrated.
At operation, a hematoma in the interhemispheric fissure extending from the right frontal lobe was evacuated. Three, instead of angiographically suspected two, aneurysms were found. One was found to arise at the site of take-off of the pericallosal artery from the azygos ACA. It was apparently unruptured, and was successfully clipped. There were two more unruptured aneurysms, one on a small branch of the azygos ACA and the other on the left proximal ACA (A₁). Both were sessile in type. They were reinforced by cottonoid sheet (Bem-sheet). Histological examination of a mass found in the clot revealed cavernoma. Postoperative course was uneventful.
Coexistence of arteriovenous malformation and cerebral aneurysm is not uncommon, but that of cavernoma and aneurysm has not been reported previously. In the present case, SAH was secondary to rupture of the cavernoma, which was not found at preoperative angiography and CT. The present case stresses that it is necessary to take into account the possibility of the presence of angiographically occult vascular lesion even in patients with SAH where aneurysm has been recognized.

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The relationship between brain dusfunction and extension of the hematoma was studied in 36 patients with hypertensive ganglionic hemorrhage by classifing the patients into 4 groups according to CT findings on admission. Brain dysfunction was evaluated by multimodality evoked potentials (MEPs) consisting cortical somatosensory evoked potential (SEP), visual evoked potential (VEP) and auditory evoked brainstem response (ABR) as reported previously. When the hematoma was localized in the outside of the internal capsule or extended to the anterior limb, 71.4% of patients showed nearly normal or slightly abnormal SEP without changes on VEP and ABR, resulting in favorable functional recovery. But, all patients with hematoma extending to the posterior limb had moderate or severe adnormality on SEP and mild abnormalities on other two modalities and 50% of the patients resulted in poor functional recovery. Severe abnormalities on all modalities in MEPs were found in the patients with large hematoma extending to the anterior and posterior limbs, or to the diencephalon. They all showed poor functional recovery or expired. Ventricular rupture of the hemorrhage had no significant effect on the abnormalities on MEPs. The functional recovery of the patients was well correlated with mild abnormality on SEP and the increase in the abnormality on MEPs associated with poor outcome. From this study, it is suggested that an analysis of MEPs as well as CT findings is valuable in the evaluation of primary and secondary brain dysfunctions and their reversibilities following the treatments.

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The attacks of cerebral infarction occur frequently during sleep or in the morning and diurnal changes of blood pressure and hematocrit (Ht) have been thought to be related to the attack.
We studied the diurnal changes of hematocrit, blood and plasma viscosity, and blood pressure in 45 patients with old cerebral infarction and age matched 15 controls. Study was performed at 10 : 00 AM, 16 : 00, 22 : 00, and next 4 : 00 AM. The results were as followed.
1) Ht and blood viscosity showed diurnal changes : minimal at 22 : 00, and maximal at 10 : 00 AM in the both groups, plasma viscosity changed slightly and showed maximum at 10 : 00 AM.
2) Ht changing ratio (ΔHt) and blood viscosity changing ratio (Δ V) were calculated by the data at 10 : 00 AM to the data at 22 : 00 as below.
ΔHt=10°-22°Ht/22°Ht×100%, ΔV=10°Viscosity-22°Viscosity/22°Viscosity×100%
ΔHt and ΔV were higher in the cerebral infarction group than in the control group.
3) ΔHt was higher in the penetrating artery infarction group (n=19) than in the cortical artery infarction group (n=18).
4) Patients with higher ΔHt and high ΔV were characterized by double or more stroke atacks episode and multiple low densities in the brain CT.
5) Diurnal changes of blood pressure was noticed neither in the patients nor in the controls.
High Ht value and high blood viscosity have been known as risk factors of cerebral infarction, and diurnal changes of Ht and blood viscosity showing maximum in the morning were also considered to be one of the risk factors of cerebral infarctions.

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A total of 242 patients with ruptuted intracranial aneurysm was divided into four age groups; (A) 70 and over, (B) 65-69, (C) 60-64, and (D) 59 and less, and studies were made with special reference to aged patients with ruptured intracranial aneurysm of 70 and over of age. In order to ascertain the characteristics of Group A, a comparison was made of clinical grade at time of admission, computed tomography (CT) findings, location of the ruptured aneurusm, complications, timing of aneurysm surgery, reason for conservative treatment, and prognosis among the groups and the following results were obtained.
1) In Group A, the number of cases evaluated to be severe at time of admission was large, 57% belonging to grade IV or V according to the classification of Hunt and Kosnik. The rate of complications was also high.
2) No difference by age could be demonstrated in the grade of subarachnoid hemorrhage on CT. The complication of hydrocephalus was high in Group A, being 26%.
3) Ruptured aneurysm was located in the internal carotid artery in 35% of the cases belonging to Group A.
4) In the early operation group up to day 2, there were many cases of poor prognosis in Group A, but no difference by age could be observed in the operation group after day 3.
5) As for the reasons of conservative treatment, advanced age was given in 19% in Group A and rerupture in 24% in Group D.
The foregoing findings suggest that careful evaluation should also be made in considering the indications for surgical treatment of aged patients.

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It is well known that the number of the neuron in the brain gradually reduced with advancing age, but speed of decline of brain functions differs among individuals. We have reported that social environmental factors had significant influences to cerebral blood flow (CBF) and mental function.
In this paper, we report 2.5 years longitudinal study concerning with CBF and intelligences in twenty normal elderly people, mean age of 76 years old at the first measurement, living in retirement house.
1) Mean CBF measured by Xe133 inhalation method did not alter significantly during the observation period.
2) Performance intelligence evaluated by Kohs' block design test had reduced at the point of begining but no more reduction was observed during the period.
3) Verbal intelligence evaluated by Hasegawa's intelligence scale for aged which was within normal range at the begining, slightly (-7.5%) but significantly (p<0.05) reduced during the period.
4) Performance intelligence tended to reduce in subjects who showed reduction of CBF. There were no significant correlation between both intelligences and CBF.
CBF could be maintained even in elderly people living in retirement house which has less social stimuli during relatively short observation period in so far as they maintain active daily life. The speed of reduction of performance intelligence may be getting slow after certain age and verbal intelligence gradually decreases perhaps by disuse of the mental function.

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