The authors surveyed the follow-up results of 512 microsurgically-treated cases with ruptured cerebral aneurysms during the last 10 years and discussed the timing and indications of surgery for ruptured cerebral aneurysms. Among these cases, 54 underwent surgery of the aneurysm within 3 days after subarachnoid hemorrhage(SAH), 57 between day 4 (the SAH day was counted as day 1) and 8, and 72 cases in the second week. Operative mortality was 5.5%, and 82.2% of the total cases returned to their previous work.
The authors' principles of surgical treatment of ruptured cerebral aneurysms were as follows:
1) Patients in Grade 1 or 2 (Hunt's grading) can safely undergo operations on aneurysms on any day after SAH.
2) During the first 3 days after SAH, cases in Grade 3 can also be operated on. Nine out of 11 cases could lead useful social lives. However, in cases of Grade 4, microsurgery of aneurysms should be postponed during this period except cases with intracerebral hematoma. Washout of cisternal blood clots was not always easy and postoperative vasospasms which exert a crucial influence on the prognosis of patients could not be prevented. Only three out of nine cases returned to their previous work.
3) Between day 4 and day 8, surgery of aneurysms in cases of Grades 3 and 4 should be postponed. Our data showed that the operative mortality of these cases was highest (33.3%) due to development of postoperative vasospasms.
4) After day 8, any cases which exhibit neurological deterioration should be subjected to repeated angiographic examinations to detect vasospasms and to follow their course. If vasospasms are present, surgery should be postponed until the vasospasms begin to subside and disturbance of the consciousness begins to improve.
Early operations (during the first 3 days after SAH) did not always prevent development of postoperative vasospasms according to our data for the last 10 years. However, recent CT scans revealed that vasospasms did not develop when no cisternal blood clots were present and complete washout of these clots by early operations can be expected to prevent postoperative vasospasms.

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Since the first description of CNV (contingent negative variation) by Walter in 1964, many reports on this phenomenon have appeared, mainly in the psychiatric field. In this report, CNV was recorded in neurosurgical patients under three experimental conditions which differed as to the level of difficulty in concentrating on the conditioned tasks. Under the 1st condition, CNV was recorded without distractive stimuli. Under the 2nd condition, CNV was recorded during distraction by definite words in a meaningless context. Under the 3rd condition, CNV was recorded during distraction by music. This was based on the fact that the amplitude of CNV is increased in the state of heightened attentiveness and concentration, and is decreased during distraction.
As a result, at least three types of CNV patterns were recognized.
In Type I, the CNV was well developed under all conditions, with slight to moderate reduction of the amplitude of CNV during distraction. Distraction by words reduced the amplitude more than by music. This type of CNV was seen among normal controls and the patients with no mental deficits and no visible CT lesions in the frontal lobe.
In Type II, CNV was already slightly inhibited under the 1st condition with further inhibition or disappearance under the other two conditions. This type was seen among patients with slight intellectual and memory disturbances and with visible CT lesions in the frontal lobe, including mild ventricular dilatation.
In Type III, CNV was not elicited at all under any conditions. This type was seen among patients with evident intellectual and memory deficits and more extensive CT lesions. In all cases with ventricular dilatation, CNV was inhibited or disappeared. In a case of hypertensive hydrocephalus treated by a V-P shunt, CNV which had not been evoked before the shunt became normalized together with clinical improvement and normalization of the ventricular size.
In another case of hydrocephalus in which ventricular dilatation remained after the V-P shunt, no CNV was elicited before or after the procedure.

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Since October 1979, real-time gray-scale ultrasonography has been intraoperatively performed on 18 patients who had previous preoperative CT examinations.
Electronic linear scanning ultrasonography was applied in the first three cases using a probe pressed against the dura mater or the brain surface with an intervening saline-filled rubber bag. This, however, proved unsatisfactory because of poor contact between the probe and the brain and also because of a relatively narrow scanning field deep in the brain.
Fifteen cases were examined using electronic sector scanning ultrasonography combined with probes of either 2.4 MHz. or 3.0 MHz. ultrasonic frequencies. After sterilization, the probe was gently pressed against the brain surface which was moistened with saline solution. The visible field deep in the brain with the sector type ultrasonography was wide due not only to the fan-shaped (78°) scanning field but also to the relatively easy manual angulation of the scanning probe. Ventricles, falx and the inner surface of the skull were always visualized, and these findings were helpful in orienting the operative field.
In five cases with early operations against ruptured intracranial aneurysms, the lateral ventricles were well visualized. In one of these cases, a ventricular tap and subsequent insertion of a drainage tube were performed with confidence and ease although the anterior horns were fairly narrow. In one case of spontaneous intracerebral hemorrhage, use of ultrasound was most helpful in selecting the corticotomy site. The extent of the hematoma cavity was disclosed by placement of a G18 ventricular needle as a marker. The introduction of the probe intracerebrally through the corticotomy gap showed no residual clot.
Among five supratentorial tumors, three subcortical tumors were visualized, but one small pituitary adenoma and one small skull base tumor were not. One subcortical solid tumor (glioblastoma multiforme) was remarkably echogenic and this was successfully needle-biopsied under ultrasonic monitoring. This should be the first step in the future development of ultrasonically-guided stereotactic biopsy. Two subcortical cystic tumors were easily punctured and aspirated under ultrasonic monitoring. However, the full extent of the needle was not well visualized even though the surface of the needle had been roughened to enhance the echogenicity. Good alignment of the needle with the fan-shaped ultrasound field using, for instance, a mechanical needle holder might give better visualization.
In one case of chronic subdural hematoma and three cases of infratentorial tumors, the pathologies were visualized although they were not particularly contributary to the operation.
Therefore, electronic sector scanning ultrasonography was useful, when combined with preoperative CT examinations, in operations on the supratentorial subcortical mass and in intraoperative punctures of the ventricles and/or cysts.

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Pathogenesis of hemifacial spasms is still obscure. To elucidate the etiology, 61 patients with this clinical syndrome were closely examined. Surgical findings of all patients and vertebral arteriograms of 51 patients disclosed characteristic changes of the vertebro-basilar artery system and its branches. The vertebral artery was invariably larger in diameter ipsilaterally to the affected side of the face, made a sharp or hair-pin like angulation at the origin of the third segment of the vertebral artery and gave off branches almost rectangularly from the top of this angulated part toward the internal auditory meatus. On the other hand, the S-shaped basilar artery with the abovementioned asymmetrical changes in diameter of the vertebral arteries gave off the anterior inferior cerebellar artery toward the internal auditory canal of the affected side with an absent or hypoplastic posterior inferior cerebellar artery. Operative procedures demonstrated that the facial nerve was invariably compressed by an ectated or radundant artery which showed right turn and local “arteriosclerotic” changes at its cross-compressing site. The peculiar vasculature changes of the vertebro-basilar artery and the compressing artery may be congenitally present, and subsequently, an exaggerated intraluminal blood stream or pressure of the larger sized vertebral artery is likely to apply a stronger hemodynamic force to the wall of the angulated part of the vertebral artery, resulting in ectasia or redundancy of the peripheral branches originating from this point and also wall thickening of the right-angled part of the compressing artery which just happens to lie close enough to the exit zone of the facial nerve from the brain-stem. These vasculature findings appear to provide an important key to solve the problem of why a certain artery can cross-compress the facial nerve and why the vast majority of hemifacial spasms develop on one side of the face.

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Three cases of small cell malignant tumors of the cerebellum from male infants were examined with light and electron microscopy and immunocytochemistry for glial fibrillary acidic protein (GFA). These studies revealed unequivocal neuronal differentiation which places these tumors into the category of so-called “cerebellar neuroblastoma” as reported by Shin et al.
Light microscopically, the tumors showed multilobulated patterns with reticulin-positive septae, not unlike those seen in so-called desmoplastic medulloblastoma. While tumor cells in the septae resembled those of a classical medulloblastoma, it was the intralobular cells that revealed ultrastructural features of neuronal differentiation. Scattered astrocytic cells and processes were also identified within the lobules by the immunoperoxidase technique for GFA. Characteristic cellular arrangements in parallel rows and fine fibrillary process formations observed light microscopically within the lobules probably represented the histologic manifestations of neuronal differentiation of the tumor.
Based on these findings, the nosologic placement of so-called “cerebellar neuroblastoma” was attempted, particularly in relation to medulloblastomas. Although histologically characteristic and ultrastructurally unique, there seemed to exist a spectrum in terms of the proportion between the neuroblastomatous area in the lobules and the medulloblastomatous area in the septae as shown in the present three cases. Therefore, the authors incline to the notion that the so-called “cerebellar neuroblastoma” is not a separate entity but a unique manifestation of neuronal differentiation occurring in medulloblastomas. However, because of the histologic resemblance, it is a distinct possibility that some of the desmoplastic medulloblastomas, especially those in younger patients, are indeed medulloblastomas showing a high degree of neuronal differentiation.

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Effects of Y-9179 and pentobarbital (PBT) on CBF, CMRO₂, SAP and EEG were studied comparatively utilizing Michenfelder's venous outflow model in dogs.
The venous outflow from the superior saggital sinus, the systemic arterial pressure and the intracranial pressure were continuously recorded on a polygraph before and during two hour's continuous intravenous infusion of these agents in the awake condition. A total of 18 dogs was divided equally into three groups. The accumulated doses during the 120 min. period for the Y-9179 and PBT groups were 4mg/kg and 40mg/kg respectively. The control group received the same amount of vehicle as the above groups. CMRO₂ was calculated as the product of CBF and AVDO₂. The oxygen contents of blood obtained from the femoral artery and the superior saggital sinus were measured by a Lex-O₂-con.
Remarkable reduction of CBF was seen with both drugs, which reached about fifty percent of that of the controls. In contrast to the pronounced increase of CVR with PBT, Y-9179 exerted essentially no effects on the CVR. The depressant action on CMRO2 by Y-9179 had already reached a plateau after 45 min, which was only about 80% of the control value. Thereafter, no additional reduction of CMRO₂ was seen in spite of continuous administration of Y-9179. There were no remarkable changes in EEG. On the other hand, PBT showed marked depressant action on CMRO₂, which reached about fifty percent of the control value. EEG activity was abolished at this point.
These experimental data suggest that Y-9179 has a lower depressant effect on the central nervous system than PBT. Therefore, it is speculated that the protective action of Y-9179 and PBT may not be based only on the reduction of CMRO2. Further investigations on the mechanism of cerebral protection by these drugs, concentrated on other possible actions such as their effects on CBF, are considered mandatory.

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Three cases of acute pulmonary edema following subarachnoid hemorrhaging due to rupture of an intracranial aneurysm were reported. Two cases had an aneurysm of the internal carotid artery and the other case had an aneurysm of the middle cerebral artery. Each case showed signs of pulmonary edema at the time of admission.
Blood gas analysis, chest roentgenography, CVP monitoring and ECG recording were repeated. The pulmonary arterial and wedge pressures were measured by a Swan-Ganz catheter inserted into the pulmonary artery in one case.
The interval between the subarachnoid hemorrhage attack and the evidence of pulmonary edema was 3, 6 and 20 hours respectively. Initial blood gas analysis revealed severe hypoxemia and the chest roentgenogram showed a typical pattern of pulmonary edema (snow storm or butterfly pattern). CVP was normal in two cases. Initial pulmonary arterial and wedge pressures were elevated and were normalized after 26 hours in one patient.
Although one case recovered from pulmonary edema by oxygen inhalation via a face mask, the other two needed artifitial ventilation with PEEP to maintain adequate arterial PO₂. Respiratory care was successful in each case. Two patients were discharged without major neurological deficits after clipping of the aneurysm. The other case died of a vasospasm on the 8th day after the subarachnoid hemorrhage.
The importance of early diagnosis and respiratory care for the treatment of acute pulmonary edema following rupture of intracranial aneurysm was stressed.

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A review of 487 cases of MLF syndrome in the literature revealed that the incidence of causes were as follows in descending order: multiple sclerosis: 48.5%, cerebrovascular disease: 32.2%, brain tumor: 5.5%, trauma: 3.9%, encephalitis: 2.7%, Wernicke's encephalopathy: 1.6%, systemic lupus erythematosus and lupus erythematosus diffusa: 0.8%, atrophy: 0.6%, Arnold-Chiari malformation: 0.4%, myasthenia gravis: 0.4%, syphilis: 0.4%, and unknown: 2.9%.
One of the authors' two cases was a 37 year-old female who was hit by a moving car from behind and lost consciousness for 5 hours, remaining drowsy thereafter. On the following day, she became alert and found it difficult to walk because of severe dizziness. She subsequently visited the out-patient clinic and showed classic findings of the MLF syndrome. This patient was observed for the following 6 months until all signs had disappeared.
Another case was a 49 year-old female who was hit by a car and lost consciousness for a while. She sustained right facial paralysis of the peripheral type. Three months after the accident, she was recommended to undergo hypoglossofacial anastomosis and was admitted to the hospital. On admission, she was found to have signs of the MLF syndrome. This patient was observed in the out-patient clinic but has not shown any evidence of recovery.
Localization of the responsible site for this syndrome has been achieved in animal experiments. The authors postulated that the lesion in these cases might be in the dorsolateral quadrant of the upper brain stem. This region is very close to that found in the autopsied cases of fatal non-missile head injury described by Adams.

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Intracranial hemorrhages associated with meningiomas are extremely rare.
A 36-year-old man was admitted with complaints of a dull headache, nausea, vomiting and a slight disorientation which persisted for a few weeks. CT showed a right subdural hematoma or effusion and high density areas in the right middle fossa and in the Sylvian fissure respectively. Right carotid angiography showed a very large avascular zone. On trepanation, a large subdural hematoma surrounded by typical outer and inner membranes was encountered and about 150 ml of dark brownish fluid was removed. A few days after the operation the same complaints as mentioned above reappeared and trepanation was repeated. Right fronto-temporal craniotomy was performed 8 days after the 2nd operation. During the operation a large subdural hematoma surrounded by firm capsules was found in the right fronto-parieto-temporal region. Part of a tumor originating from the right lateral third of the sphenoidal ridge protruded through the inner membrane into the hematoma cavity. A few small tumors were also found within the hematoma cavity. Most of the hematoma capsules and the tumor masses were removed and also another tumor mass growing in the Sylvian fissure was partially resected. Histological examinations showed the tumor to be a meningotheliomatous meningioma with sarcomatous changes.
The patient died less than one month after the last operation. Postmortem examination disclosed numerous metastatic tumor masses throughout the central nervous system.
Including the present case, a total of 15 reported cases of meningiomas associated with intracranial hematomas were reviewed and discussed.

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Although plasma-cell tumors are usually multiple and located in the bones, the occurrence of a single plasmacytoma in the soft tissue has been reported. However, only 13 cases of solitary intracranial plasmacytoma has been reported. This report describes such a case which was recently experienced. The patient was a 45 year-old man who was admitted because of visual disturbance and mild left hemiparesis. Neurological examination revealed bilateral choked discs, left homonymous hemianopsia and mild left hemiparesis. Laboratory examinations were within normal limits. Bone X-ray films and scintigraphy of the whole body showed no abnormalities. Bence-Jones proteinuria, hyperproteinemia and abnormal plasma cells in the bone marrow were not found. The absence of abnormal protein in the serum and urine was confirmed by immunoelectrophoretic examination. Right carotid angiography revealed a homogeneous vascular stain in the parieto-occipital area in the late arterial phase. ^99mTc brain scan showed a hot area in the same location. Cranial CT scan showed a low density area which was surrounded by an irregular-shaped high density area in the parieto occipital lobes. This was subtotally resected. The tumor was not attached to the dura mater. Histopathological examination of the tumor revealed a typical plasmacytoma. In the cytoplasm of the tumor cells, Ig-M was detected by the enzyme labeled antibody method. The postoperative course was uneventful.
A short review of the world literature concerning diagnosis, treatment and prognosis of solitary intracranial plasmacytomas is included.

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