We attempted a pressure study of subdural fluid in 26 infant and child patients. The method used in the pressure study was as follows: a continuous recording was carried out with a polyethylene catheter inserted into the subdural fluid and connected to an externally placed pressure transducer and an amplifier chart recorder. The subdural pressure was measured by continuous recording over a period of 36 hours and then the subdural pulse waves were analyzed.
The subdural mean pressures were classified into three patterns, namely A) continuous high pressure (more than 200 mm H₂O), B) intermittent high pressure, and C) continuous low pressure (less than 100 mm H₂O).
Generally, both high pressure patterns were recognized in cases presenting light head injury or meningitis. Reexpansion of the brain was observed following surgical procedures in such cases. On the other hand the continuous low pressure pattern was observed in cases of brain atrophy following serious traumatic event and unknown etiology, and re-expansion of the brain was not obtained by surgical procedures.
In analyzing pulse waves, polyphasic patterns were observed in cases of light traumatic event or unknown etiology. However, arch-like patterns were observed in cases where severe atrophic change of the brain occurred after various original diseases.
The intracranial cavity contains three constituents, i.e., brain tissue, cerebrospinal fluid and blood. When the equilibrium of the three is disturbed, there is subdural collection of fluid to compensate for brain damage and changes in subdural pressure.
We therefore consider measurement of subdural pressure and analysis of pulse waves to be significant in estimation of the degree of brain damage and to provide information for therapeutic indications.

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In 1967 we proposed, in cases of hypertensive intracerebral hemorrhage, that operative treatment be carried out in the per-acute stage or surgery within 7 hours after ictus, and stressed the importance of the time factor. Now, after sufficient time has elapsed for observation, we would like to reevaluate the result of surgery in the peracute stage as compared to other operative series in the later stage and to non-operative series.
During the past 7 years, 300 cases of hypertensive intracerebral hemorrhage, including 166 cases of the lateral type or putaminal hemorrhage, have been admitted. Operation in the per-acute stage was carried out in 84 cases presenting definite surgical indications. Delayed operations were performed in 36 cases. Operation was not indicated for the remaining 46 cases as some were too severe and the others too mild. A comparison was made of several items, such as neurological grading on admission and condition at discharge using ADL classification of functional recovery.
As a result, the per-acute operation series was observed to have much better functional recovery as compared to the other series: 82% of all per-acute operation cases were discharged with ADL grade 3 or better, or they could at least walk with a cane. In the lateral type of hypertensive intracerebral hemorrhage series, 66% of the cases were discharged with ADL grade 3 or better. A more marked difference in the outcome was noted in the group of severe cases in which there was a state of semicoma or worse at admission: more than 60% in the per-acute operation series were discharged with ADL grade 3 or better, whereas only 30% in the delayed operation group could be discharged with ADL grade 3 or better.
Eight patients in the per-acute operation series died: two with myocardial infarction, two with reaccumulation of hematoma, one of G. I. bleeding, and three of fulminant progression immediately before surgery.
To conclude, this study reconfirmed that operation in the per-acute stage is advantageous in cases of the lateral type of hypertensive intracerebral hemorrhage.

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The preoperative condition, surgical treatment, postoperative management and results of 17 cases of a severe type of ruptured intracranial aneurysm operated on within 8 hours after the last subarachnoid hemorrhage were reviewed. The criterion for this severe type of ruptured intracranial aneurysm was designated as grade 4 or 5 according to Hunt and Kosnik. The 17 cases were divided into two groups on the basis of the method of treatment. In the first group of 6 cases, a simple per-acute operation was performed, mostly prior to 1977. Severe vasospasm was frequently encountered on the 3 or 4, postoperative day, and the long-term results were unsatisfactory except in one case which showed improvement soon after evacuation of the associated massive intracerebral hematoma.
In the remaining 11 cases, two silicone catheters were left in the basal cistern after clipping of the aneurysm if severe subarachnoid hemorrhage was present. Repeated irrigation was carried out for 7 days at the most using 500 or 1, 000 cc of saline solution or lactate Ringer's solution each time. This resulted in a remarkably decreased incidence of late vasospasm. As a result, 4 of the 11 patients were able to lead a social life and 4 an independent home life.
Other group of 16 cases of a severe type of ruptured intracranial aneurysm were admitted within several hours of an attack and followed up for 7 days at the most while being administered conservative treatment using corticosteroid, antifibrinolytic agents, and so on. Ten of the 16 cases died within 24 hours, and 4 thereafter. Only two cases survived for more than 7 days and had successful radical surgery.
It is concluded that the best method of treating a severe type of ruptured intracranial aneurysm is to operate as soon as possible and to carry out repeated irrigation of the basal cisterns if severe subarachnoid hemorrhage is noted during the operation.

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Adult dogs having had 0.5 ml/kg of autogenous blood injected into the great cistern to simulate subarachnoid hemorrhage (SAH) were employed. These animals were either treated with trans-4-aminomethyl cyclohexane carboxylic acid (t-AMCHA) or left untreated, and were then investigated for changes in (1) fibrinolytic activities as measured in terms of SK-euglobulin lysis time and fibrin plate method, (2) plasma fibrinogen and FDP contents and viscosity of the blood (whole blood and plasma) and (3) cerebral blood flow (CBF), EEG and intracranial pressure (ICP) under arfonad or chlorpromazine-induced hypotension. The CBF was measured both by thermister method and by hydrogen clearance method.
1) The fibrinolytic activity in peripheral blood did not increase to a noticeable extent during the acute stage of SAH but rather showed a decline, which became particularly prominent when spasm of cerebral vessels occurred. The administration of t-AMCHA (0.2 g/kg) was followed by a significant inhibition of fibrinolytic activity.
2) The fibrinogen and FDP contents of blood showed an increasing tendency concurrently with the cerebrovascular spasm. Moreover, this tendency became even more pronounced after the administration of t-AMCHA. Administration of this antifibrinolytic agent was also attended by a significant increase in the viscosity of blood.
3) CBF values found on the 1st and 2nd days after the onset of SAH and after the 7th day ranged between 55.4 and 62.4 ml/min/100 g brain, being virtually within the normal range. However, values on the 3rd, 4th, 5th and 6th days, notably the 3rd and 4th days, were somewhat lower than the normal range. Drug-induced hypotension (40-50% of control level) was followed by an initial transient decrease in CBF with a subsequent return to normal CBF earlier than the recovery of blood pressure on the 1st, 2nd and 7th or later days after the onset of SAH. On the 3rd, 4th, 5th and 6th days of the onset of SAH, especially the 3rd to 4th days when the cerebrovascular spasm was at its height, a comparable degree of hypotension gave rise to a marked decrease in CBF (about 70% decrease being observed in arfonad treated cases) and, occasionally, associated with prolonged flattening of EEG waves which suggests irreversible changes in the brain. Chlorpromazine produced less changes in CBF than arfonad.
In conclusion, CBF decreases to a certain extent in association with vasospasm, and hypotension induced during this period may give rise to serious impairment of cerebral circulation.

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Brain infarction confined to the anterior half of the thalamus can be produced in dogs by simultaneously occluding 4 main arteries ipsilaterally at the base of the brain (the internal carotid, the anterior cerebral, the middle cerebral, and the posterior communicating arteries). Using this “thalamic infarction model in the dog”, hemorrhagic infarction following recirculation was investigated.
In animals undergoing 6-12 hour occlusion, a high incidence of hemorrhagic infarction was found following recirculation. Notably, in brains autopsied 1 hour after recirculation, hemorrhagic infarction was seen in all (100%) of the dogs.

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Seven cases of syringomyelia were treated by simple suboccipital craniectomy, syringotomy, CSF shunt or a combination of these. The suboccipital craniectomy was performed on 5 patients. The procedure consists of craniovertebral decompression, incision of the dura and dural plasty using nuchal fascia graft. A case associated with arachnoiditis of the cisterna magna and another case with advanced neurological deficits showed less improvement. Remarkable improvement of symptoms was observed in the remaining 3 patients. Ventricular dilatation was observed in a patient who was treated by ventriculoperitoneal shunt.
A review of the literature and our surgical results suggest that the surgical decompression of the posterior fossa and upper cervical spine results an improvement in most patients with a small incidence of postoperative complications. In cases with severe adhesive arachnoiditis of cisterna magna, vigorous direct approach to the herniated cerebellar tonsils may produce irreparable damage to the medulla. Early surgical treatment aimed at restoring normal CSF dynamics of the cisterna magna is emphasized for patients with communicating syringomyelia.

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Pathogenesis of periventricular lucency was investigated. Periventricular lucency noted in acute hydrocephalus may represent periventricular edema and disappears in a short time after a shunting operation. Periventricular lucency in chronic and normal pressure hydrocephalus is presumed to be a consequence of water retention combined with a disturbance of the blood circulation in the white matter. Periventricular lucency in hydrocephalus is considered to be a reversible phenomenon and may be regarded as a sign of present or preceding intraventricular hypertension. It may provide a useful criterion for a shunting operation. Periventricular lucency encountered in diseases other than hydrocephalus is supposed to be leukoencephalopathy in the arterial borderzone which is vulnerable to hypoxic-ischemic events. These two different periventricular lucencies should be differentiated.

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Thirty post-surgical patients with various intracranial lesions were examined by both computed tomography (CT) and ultrasonography (US) to compare clinical efficacy.
Ultrasonography with gray-scale electronic linear scanner was taken through post-surgical bone defect after routine CT examination had been completed.
In fifteen patients, good correlation was obtained between these two modalities. As for detection of the hydrocephalus, US showed 93% accuracy. In eleven cases, CT was superior to US in the diagnosis of brain edema and infarct.
In four cases, US detected clinically useful information which CT failed to demonstrate.
US can be a good imaging modality for post-surgical intracranial lesions. A certain portion of CT examinations can be replaced with US which will reduce the cost and radiation dose for the patient.

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Effects of pial incision and steroid administration on experimental spinal cord injury were examined. Using the weight dropping method, we induced spinal contusions in dogs at the level of T₉ or T₁₀. 500 gm-cm impact on canine spinal cord resulted in complete paraplegia lasting one month after trauma. All eight dogs, treated with wide pial incision of the contused spinal cord one hour after trauma, could stand or raise their hips, but none could walk or run. Early steroid administration gave rise to similar benefits as pial incision in four out of five dogs. It is postulated, therefore, that true external decompression for cord swelling or edema would necessitate not only laminectomy and dural incision, but also wide pial incision. Functional recovery obtained by pial incision only was much worse, compared with that of early myelotomy and irrigation as previously reported.

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