Eighty two clinical cases of acute intracranial hematoma due to apparent head injury were examined and treated in past 10 years. These clinical cases were analyzed based on clinical history, type of trauma, symptomatic signs and methods of their treatment. It is strongly suggested that the acute subdural hematoma should be reclassified on the basis of its mode of clot formation and not to confuse with post traumatic subdural liquid collection, in rather chronic form.
Acute subdural hematoma which predominantly occur in male, was experienced on 40^-1 clinical cases and it was classified in type I & type II. Type I acute subdural hematoma occurs following a rather mild injury such as fall on floor without fracture. This type is frequently seen in infants of approximately 10 to 14 months of age. A rather huge clot is usually found in frontal area probably due to a tear of a large vein in the frontal lobe. No severe primary brain damage is associated and operative results are usually good.
Type II are always accompanied with some degree of brain damage and traffic accidents were the most frequent cause. Post operative results were varied in accordance with degree of primary or secondary brain damage and even with extensive external decompressive craniectomy, their prognosis were poor in some cases.
Extradural hematoma was experienced on 40 cases and 8 of them were under the age of 2. An initial loss of consciousness was absent in most of cases which made the diagnosis very difficult, thus delay in surgical operation or in referral to the neurosurgeons was experienced.
Fractures were found in parietal area in more than 90% of cases therefore a burr hole in parietal area as an initial operative procedure is suggested.
Local neurological findings were absent in 12 cases out of 40 and the most predominant clinical signs were pale face with pre-shock state, repeated noxious vomiting and consciousness disturbance.

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A 65 years-old man was admitted as a case of brain tumor. Eight months prior to admission he started paroxysmal uncontrollable laughing, and one month later, he developed a left hemiparesis with headache. Upon admission, slight choked disk and left hemiparesis were noted. Deep tendon reflexes were a little brisker on the left than on the right, but no pathological reflexes were present.
The most striking symptom was occasional uncontrollable laughing without any recognizable reason. Duration of each episode was less than 20 seconds and the attack occured as often as 6-7 times a day. While laughing, neither vascular flushing of the face nor convulsion was noticed. During the attack, he did not seem to feel any emotion appropriate to laughter (Fig. 1).
EEG showed polymorphic delta waves in the right fronto-centro-parietal regions and no definite epileptic patterns, even at the time of attack (Fig. 2). A right carotid angiogram revealed a localized tumor staining in the posterior frontal region (Fig. 4). The tumor was totally removed, and was confirmed histologically as angioblastic meningioma (Fig. 5). There has been no episode of laughing during the past two years after surgery.
From the literature relating to the anatomy and physiology of the thalamus, hypothalamus, their cortical connections and their relationships with the limbic structure of the temporal lobe, we discussed the central mechanism of disordered laughter resulting from focal cerebral lesions, such as brain tumor, and we may say such lesions at various levels cause pathological laughing.

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The incidence of recurrence was examined in 174 patients with completely removed meningioma. The material consisted of 284 surgically treated cases with meningioma from January 1941 through March 1976. Following operations of grade III (Simpson), there appeared to have been 16.1 % of recurrence, 20.0% following operations of grade II and 18.8% following ones of grade I. The recurrent site of tumors was, convexity, falx, olfactory groove, parasagittal, tuberculum sellae and sphenoid ridge, in decreasing frequency.
Eight out of 17 malignant meningiomas (47%) and 1 out of 4 hemangiopericytoma type of angioblastic meningiomas recurred. Out of 149 tumors diagnosed as benign meningiomas in the original operations, 19 (12.7 %) recurred. The recurrence rate was 13.3% in meningocytic meningiomas and 9.5% in fibroblastic ones. Most recurrent meningiomas did not show morphological changes. However, 6 out of 19 recurrent meningiomas (31.6%) showed histologically malignant changes. All 6 tumors had been meningocytic in the original operations. All the histologically malignant meningiomas carried also malignant biological character.
Even after excluding those diagnosed as malignant in the original operations, the recurrence rates were 5.7% in grade III operations, 16.9% in grade II and 14.6% in grade I operations. The recurrent site of originally benign meningiomas was following in decreasing frequency; falx, olfactory groove, convexity, parasagittal and tuberculum sellae.
It was not established whether prophylactic radiation therapy was effective in preventing repeated recurrence in benign meningiomas.

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To evaluate the hypothalamo-hypophyseal function after surgery of the ruptured anterior communicating aneurysm, the reserve of adenohypophyseal hormones (GH, ACTH, TSH, Prolactin, LH and FSH) was determined in 30 patients who had undergone microsurgical procedures. GH was studied during the insulininduced hypoglycemia. The LH, FSH, and TSH reserve was studied by means of LH-RH and TRH administration. ACTH-cortisol axis was evaluated by determining urinary 17-OHCS and serum cortisol levels. These 30 patients were divided into 3 groups based on their preoperative state of consciousness; Group A: fully alert (Grade I of Bottrell's classification, 15 cases), Group B: mildly impaired (Grade II, 10 cases) and Group C: severely damaged (Grade III to V, 5 cases).
In 12 of 30 cases GH secretion was found impaired after surgery, but TSH, LH and FSH secretion were impaired only in 4 cases. Seven out of 13 cases in Group A and B had endocrine dysfunction within 3 months after subarachnoid hemorrhage (SAH) and only one of 12 cases had it thereafter. On the contrary, 2 of 5 cases in Group C was examined later than 6 months and both of them had impaired function.
GH secretion was impaired in 2 out of 6 cases who had transient postoperative deterioration of consciousness and not in the other 4 cases, suggesting that the influence of microsurgical procedures on endocrine function may be slight.
The hypersecretion of TSH, LH and FSH was observed in 11 out of 25 cases in Group A and B with or without impairment of other hormone secretion. None of them had hypothyroidism or hypogonadism clinically and thyroid hormone secretion was found increased in 2 cases.
Morning resting levels of serum cortisol determined in 10 cases showed higher levels in 4 cases within 5 weeks after SAH and normal levels in 6 cases after 8 weeks. The pre and post-operative dexamethasone therapy did not suppress serum cortisol levels in the early phase after SAH.
These data suggest that the postoperative endocrine disorders may be reversible in the state of mild impairment of consciousness and irreversible in the severely impaired state. In the former state the transient hypothalamic hyperfunction may also occur.

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Anterior pituitary function was evaluated in 17 patients with cerebrovascular disease, i.e., 12 cases of intracranial aneurysm, 2 of arterio-venous malformation, 2 of traumatic carotid-cavernous fistula and 1 of idiopathic subarachnoid hemorrhage. Anterior pituitary function was assessed by plasma levels of GH and cortisol in ITT, of TSH and prolactin (PRL) in TRH test, of LH and FSH in LH-RH test. These examinations were performed between 2 and 60 days after the attack of subarachnoid hemorrhage or head injury and no drugs were administered that could interfere the test used.
1) GH, TSH, ACTH (cortisol), LH, FSH and PRL secretions were impaired in 23%, 35%, 6%, 6%, 6% and 0% of the cases respectively. However, these hyporeactive cases showed only slightly lower peak levels than the lower limit of the normal range.
2) Impaired TSH secretion were found only in patients with intracranial aneurysm, especially in the 4 patients with internal carotid artery aneurysm.
3) A patient who had a giant aneurysm at the internal carotid-ophthalmic portion, about 4.5 cm in the diameter, revealed the pattern of so-called hypothalamic hypopituitarism, that was elevated plasma levels of PRL and impaired secretion of other pituitary hormones.

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1. Emergency operations were performed on 27 consecutive cases admitted to Shizuoka Rosai Hospital within 5 days after the last episode of subarachnoid hemorrhage from January 1974 through the end of June 1976. The results included 22 cases (81.5%) who could return to social life and 2 fatal cases (7.4%).
2. Among these the surgical results were not varied by the time elapsed after the last episode of subarachnoid hemorrhage, if it was within the period of 5 days. One case showed vasospasm before surgery, which did not affect the postoperative course. A symptomatic vasospasm was observed only in one other case postoperatively.
3. The site of aneurysm did not influence the surgical results. Hence a vertebrobasilar aneurysm could be operated upon on an emergency basis.
4. There were no differences in the surgical results according to the grades I to IV (cooperative study, Nishioka) except for elderly patients of grade IV.
5. As for the age, the patients with grade IV over the age of 65 years sustained a poor postoperative prognosis.
6. Since a high blood pressure is one of the risk factors for rerupturing, a hypertensive patient is a good candidate for the emergency operation.
7. In order to perform the surgery on an emergency basis successfully it was essential to eliminate any complicated procedures before and during the surgery to save time. For this purpose with the use of neuroleptanalgesia the operations were performed under normothermia with temporarily induced hypotension. Skin shaving of the operating field, blood transfusion and administration of antibiotics were unnecessary. Operating time ranged from an hour and a half to 4 hours, mostly within 3 hours. Neither ventricular nor cisternal drainage were usually indicated.
8. Routine procedures included adequate irrigation of the blood in both subarachnoid space and basal cistern and opening of the Liliequist's membrane to facilitate enough communication between supra and infratentorial CSF pathways. With early postoperative RI-cisternographies no blockage in the basal cistern was observed.
9. Ruptured aneurysms should be and could be operated upon as quickly and safely as possible only with a well-arranged emergency surgery unit and squad in the hospital and with the skilled hands of neurosurgeons.

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Thirty-one cases of anterior communicating aneurysm operated on under microscope within 2 weeks after subarachnoid hemorrhage (SAH) were analyzed with regards to time courses of their morbidity, especially mental symptoms after surgical treatments.
Six out of 15 cases operated on within 7th day after the last SAH (the day of the last SAH was counted as the first day) showed slight disorientation and recovered within 2 weeks (Fig. 2, 4). Seven of remaining 9 cases became drowsy due to postoperative vasospasm appearing in the 2nd week after SAH and one case died. In the 3rd week, these 7 cases demonstrated Korsakoff syndrome after recovery of consciousness and 6 became apathetic due to Normal Pressure Hydrocephalus (NPH) and 4 of them recovered by ventriculo-peritoneal shunt(V-P shunt) in the 2nd month after SAH.
Sixteen cases underwent direct operation on aneurysm between the 8th and 15th day after SAH and 3 died : one was operated on with Hunt's grade V and 2 showed rebleeding from aneurysm during craniotomy. Six out of 13 cases demonstrated consciousness disturbance or Korsakoff syndrome due to preoperative vasospasm in their preoperative states and showed more or less deteriorations in their symptoms after operations (Fig. 6). Five cases received V-P shunt and 3 recovered completely in their mental function in the 2nd month after SAH.
Follow-up results of cases operated on in the acute stage were not bad comparing with those of cases operated on after the 3rd week after SAH (Table 2). In the surgical treatments of cerebral aneurysm in the acute stage, vasospasm and hydrocephalus are most important factors affecting the prognosis of patients and mental dysfunctions usually recovered by V-P shunt at latest in the 2nd month after SAH. In 5 cases which were operated on in the acute stage and showed residues of mental dysfunctions in their follow-up results, aneurysms were all located in the interhemispheric fissure and such complications as vasospasm and hydrocephalus occurred severely in their courses.

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Diagnosis of thalamic hemorrhage has become more accurate by CT scan, and the precise location and extent of hematoma can be visualized preoperatively, as well as postoperatively, i.e. the follow-up study showing the outcome of hematoma and secondary changes of the brain is more readily available. Operative procedure for such a lesion should be reevaluated.
Thalamic hemorrhage constituted 27% of all hypertensive intracerebral hemorrhages in our series (the reported incidence was not so high).
According to CT findings (except for 3 cases with giant hematoma), we could classify their main locations into 3 types as follows; —1) anterior type — located in the anterior nuclear group of the thalamus — 2 cases, 2) medial type located in the medial nuclear group of the thalamus — 2 cases, 3) posterolateral type located in the lateral nuclear group of the thalamus — 5 cases. As to the extention of hematoma, we devided all cases into the following 5 types; Type I — localized in the thalamus, Type II — medially extending & perforating into the third ventricle, Type III — laterally extending into the internal capsule and the basal ganglia, Type IV — spreading into all directions, Type V giant hematoma. This classification was found useful in relation to the clinical picture, the operative decision, the choice of operative method and the postoperative prognosis.
The onset of the clinical picture was always sudden and included disturbance of consciousness and hemiparesis or hemiplegia. Of 8 cases which allowed a satisfactory clinical examination of sensory and motor function, only few cases showed signs of the thalamic syndrome. In 2 cases of giant hematoma with extensive spread, downward deviation of the eyeballs was noticed.
Surgery should be performed; with exceptions to the following conditions — 1) no agreement of family, 2) over 75 years of age, 3) already representing the symptoms of brain stem, 4) severe associated deseases, 5) mild case (mainly level of consciousness).
Based on CT findings the most suitable operative procedure should be adopted, — that is, only unilateral C.V.D. (continuous ventricular drainage) on localized type, bilateral or unilateral C.V.D. on medial type, trans-paracallosal approach on anterior type and posterolateral type, trans-temporal approach on lateral extention type, trans-paracallosal or trans-temporal approach combining irrigation-evacuation of the intraventricular clots on giant hematoma type and all extention type.
Out of 12 cases six survived, and 3 cases have useful life. Relatively better prognosis was obtained in medial type, and in posterolateral type, but giant hematoma type and all extention type resulted in the worst outcome. In marked lateral extention type of posterolateral type improvement of hemiplegia was not good. Except for the massive intraventricular hemorrhage, the prognosis was dependent on the grade of deterioration of the thalamus, hypothalamus, and the midbrain rather than the ventricular perforation. Even if hematoma was not so large, delayed surgical treatment for C.S.F. obstruction due to ventricular perforation carried the poor prognosis on mortality and morbidity.

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Recently ventriculo-peritoneal shunt (V-P shunt) operations are being performed widely in pediatric patients with hydrocephalus. One of the problems in the management of shunt dependent hydrocephalic infants is the evaluation of the patency of the shunt system. This is a report of shuntgraphy and flushing device manometric test to determine the function of the V-P shunts utilizing the Pudenz valve.
A 23 gauge needle is inserted into the Pudenz flushing device. The needle is connected with vinyl tube of 50 cm in length. The ventricular pressure can be measured by this technique when the proximal tube is patent. The vinyl tube is filled with normal saline or cerebrospinal fluid. The fluid slowly moves down to the level of 50-150 mmH₂O in cases of normal function of the shunt, but if the distal catheter is obstructed the fluid will not descend and stay in the vinyl tube. Then Conray 60%, or Dimer X 1.0 ml is injected with pressure into the flushing device under fluoroscopic control. In most of the cases the dye flows to distal tube even though the distal shunt system is not well functioning, then 1-4 ml of Conray 60% is added for better visualization and spot films are taken. If reflux of the dye into the lateral ventricle occurs, further injection of contrast material is abandoned.
We have performed this test for 50 V-P shunt implanted hydrocephalic children aged between 3 months and 8 years, who have had 54 shuntgrams in all. The locations and causes of the distal catheter blockage were determined in 34 patients. Several kinds of malfunction of V-P shunt distal catheter were demonstrated.
The findings of shuntgrams are as follows:
1). Capsule formation of the whole distal catheter. 7 cases
2). Blockage of the lower end of the catheter. 6
3). High ventricular pressure without blockage of the shunt system. 4
4). Cyst formation at the lower end of distal catheter. 4
5). Kinking of the distal catheter at the cervical region. 3
6). Disconnection of the distal catheter. 3
7). Localized perfusion of the contrast material in the peritoneal cavity. 3
8). Others. 4
This test has been proved to be simple, safe and reliable in the evaluation of the eventriculo-peritoneal shunt evaluation.

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