Experimental cerebral infarction was induced in dogs by injecting one or two silicone rubber cylinders through the cervical internal carotid artery. Twenty-four hours after embolization, the animals were sacrificed and changes of microvessels in the hemispheric infarct were investigated by the electron microscope. In addition to the usual ultrathin sectioning method, the vascular casting method using Mercox® in combination with the cryofracture method, and the freeze-fracture replica method were also used. Gross specimens and histologic sections revealed that massive hemorrhagic areas were localized in the region of basal ganglia and petechial hemorrhages were observed in the corticomedullary junctional region of the affected hemisphere in the middle cerebral artery distribution. In ultrathin sections of arterioles obtained from the infarcted area of the basal ganglia, vacuolations and bleb-formations of the degenerative endothelial cells and smooth muscle cells, and duplications and fragmentations of the basal lamina appeared, while numerous red blood cells and fibrin materials were observed in the dilated subarachnoid space. In vascular casts of these 50, um diameter arterioles, aneurysm-like dilatations were observed at their bifurcations, where numerous red blood cells and Mercox® massively extravasated through the disrupted wall in the necrotized neuropils. Red blood cells in the dilated subarachnoid space were observed in the ultrathin sections of venules in the corticomedullary junctional region, but the degenerative changes were mild. In vascular casts of venules, leakage of Mercox® was observed around the adventitia. It is suggested that a massive hemorrhagic infarction was caused by the disruption of arterioles in the perforating arterial terminal zone and petechial hemorrhagic infarction was caused by the disruption of venules in the cortical arterial terminal zone. No opening of tight junctions was recognized in the ultrathin sections of capillary endothelial cells in the ischemic cerebral cortex, but pinocytotic vesicles increased. In freeze-fracture replicas of capillary endothelia of both normal and ischemic cerebral cortices, tight junctions were seen as a network of ridges, composed of about 100 Å particles on the protoplasmic (p) face and grooves on the exoplasmic (e) face. Pinocytotic vesicles were seen as invaginations on the p face and as protrusions on the e face. The average number of pinocytotic vesicles per μm² was 7 on the luminal front in the normal cortex and 28 in the ischemic cortex. The size of pinocytotic vesicles was 0.62 X10-2 μm on the p face of the normal cortex and 0.83×10^-2μm on the p face of the ischemic cortex. It is suggested that pinocytotic vesicles had a more important role in the increase of permeability in the cerebral capillary endothelial cells of the ischemic brain.

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In order to see the cerebral arteries as continuous stereoscopic views, a new device for serial rotatostereocineangiography has been devised. A rotating ring, USZ-30, which is a device for Xray fluoroscopy using television, was utilized as a gantry, in which an X-ray tube and an image intensifier were installed, resulting in the same rotating center as the ring. The gantry is manually rotated from the lateral to the contralateral (180°) position in about 1.8 seconds. Because of the difference in density of the skull in the anteroposterior versus lateral positions, an aluminum filter was designed to correct this difference. A polyethylene bucket, with the bottom removed, was used as the head supporting device to avoid a shadow on the film. In order to control the exposure during rotation, two microswitches were used along with a cycle counter to measure the speed. A 35 mm cine film analysis projector, Nac 350, was modified, so as to project the adjacent cine film frames simultaneously. An observer can view the pictures of the cine film stereoscopically, using an adjustable stereoviewer, constructed with an over-screen hood, which corrects the human pupillary distance with mirrors.
Using the Seldinger technique, 15 ml of contrast medium were injected into either the internal carotid, external carotid or vertebral artery while rotating the gantry manually. Exposures taken at five degree intervals using an Arritechno 35 mm cine camera at the speed of 20 frames per second provided adequate stereoscopic views of the cerebral circulation when adjacent cine frames were observed through the adjustable stereoviewer. The afferent and efferent lesion vessels, such as aneurysms, arteriovenous malformations, carotid cavernous fistula or vascular tumors, could be observed using this method.

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The authors already reported that the incidence of the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) after subarachnoid hemorrhage (SAH) was significantly higher in patients with Grade III and IV of Hunt and Hess, severe vasospasm and marked hydrocephalus than in patients without these factors. In order to clarify why the patients with these factors were susceptible to develop SIADH after SAH the plasma ADH level (PADH) in 25 control subjects and in 56 patients with SAH mainly due to cerebral aneurysms were measured using radioimmunoassay. PADH measurements, repeated 111 times, were made preoperatively within 4 weeks after SAH.
PADH in 13 cases with SIADH was significantly higher than those of the control and were inappropriate for the corresponding serum osmolarities. The differences in PADH, according to clinical grades, vasospasm, hydrocephalus and aneurysmal locations were studied in 43 cases without SIADH. The results were as follows: 1) PADH in patients with Grade III and IV, specially measured within 14 days after SAH, was significantly higher than that in patients with Grade I and II. 2) Patients with mild or severe vasospasm had significantly higher PADH than patients without vasospasm. 3) In patients with hydrocephalus, the PADH was significantly higher than that without hydrocephalus. 4) The differences in PADH according to aneurysmal locations were not significant. Hematological and urinary studies showed that the excessive release of ADH recognized in the present study was a non-physiological (inappropriate) release of ADH, caused by non-osmotic factors, except blood volume depletion.
These results suggest that the patients with Grade III and IV, vasospasm, and hydrocephalus in the acute stage after SAH are unable to suppress ADH release and to excrete the water load normally, even if they are under normoosmotic conditions. The present study supports the previous report by the authors that the patients with Grade III and IV, severe vasospasm, and marked hydrocephalus are susceptible to SIADH.

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Results of the treatment in 107 patients with germinal tumor in this department for the past 31 years were studied. The mortality rate during hospitalization was 27%. In particular, the mortality rate after resection of the tumor was as high as 35%. The mortality rate during hospitalization for the 10 year period since 1971 was 14%, indicating an improvement. The five-year survival rate was 50% for all and 69% for the 32 patients for the 10 years since 1971. There was no significant difference in the survival rates between the patients who received radiation therapy after resection and those who received only irradiation therapy. Of the patients who were treated by irradiation alone, the three-year survival rate was 75% in patients who received irradiation both to the whole brain and to the local region, showing the most favorable result. There was no significant difference in age, sex, duration and site of the disease and the mode of treatment between patients who survived over 5 years and those who died within 5 years. Tissue studies disclosed that germinoma was in the majority. As for germinoma in the pineal body, 16 of the 19 patients in whom the tumor was located in the posterior part of the third ventricle survived over 5 years, suggesting the importance of early diagnosis. The one-year survival rate for patients with highly malignant germ cell tumors was 14%. There was no patient with this tumor who survived for two years or more. Metastasis to the spinal cord occurred in 40% (2/5) of the patients with embryonal carcinoma, 3% (2/64) in patients with germinoma, and 5.2% (4/77) of all patients with germinal tumors.

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Gliomas are sometimes encountered which are not noticeably enhanced in initial computerized tomography (CT) scans. The sequential CT findings of such gliomas, including three malignant astrocytomas, three benign astrocytomas and one malignant oligodendroglioma, were evaluated. The initial symptoms in all subject cases were convulsive seizures. There was no correlation between the mass effect of the low density zone and the grade of histological malignancy. Rather, malignant gliomas disclosed less prominent mass effects, despite the later appearance of an enhanced high density zone. In one case each of malignant astrocytoma and of malignant oligodendroglioma, an enhanced high density zone first appeared 6 to 13 months later. Neither gave evidence of increasing mass effects, either during the follow-up or after appearance of the enhanced high density zone.
Questionable low density zones in CT scans should be followed-up for at least 6 months or more in conjunction with other studies.

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The relationship of clinical manifestations to hematoma volume and regional cerebral blood flow (r-CBF) was analyzed in 65 adult patients with chronic subdural hematoma (CSH). Hematoma volume was measured in computed tomographic scan images with a semi-automatic analyzer (Leitz ASM), and r-CBF by ¹³³Xe inhalation method. Headache, hemiparesis, and later consciousness impairment occurred with increase of hematoma volume. Headaches due to increased intracranial pressure were common in younger patients, while a third of the aged cases with neurological deficits complained of no headaches. Older patients who retained CSH over 3 months showed mental symptoms. Neurological deficits occurred in cases with over 95 ml of hematoma in the 40 to 60-year age group, and over 120 ml with those aged over 60 years. The degree of the midline shift in unilateral CSH was not always correlated with hematoma volume. Such differences in the critical hematoma volume and the degree of midline shift were probably due to age-dependent changes in the brain weight and intracranial free space. Twenty cases with unilateral CSH showed bilateral decrease in r-CBF. The r-CBF in the hemiparesis group decreased especially at the frontal and parietal lobes, ipsilateral to the hematoma.

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The authors are presenting two patients with subclavian steal syndrome successfully treated by axillo-axillary bypass or by percutaneous transluminal angioplasty, and discuss the choice of procedures for the correction of the subclavian steal syndrome.
The first patient was a 48-year-old man complaining of easy fatiguability of the right arm and vertigo. No neurological abnormality was found, but the blood pressure was 160/90 mmHg in the left arm and 120⁄90 in the right. Angiograms revealed complete occlusion of the innominate artery and retrograde filling of the right vertebral artery. Axillo-axillary bypass was performed using 8F Dacron velour graft under general anesthesia. After surgery, the patient was free from any symptoms and the patent axillo-axillary bypass and antegrade flow of right vertebral artery were observed on postoperative angiograms.
The second patient was a 58-year-old man who experienced an episode of motor weakness of the left upper and lower extremities and speech disturbance 8 years before admission. Although neurological examination was within normal limits except for a slight left hemiparesis and there was no difference between the blood pressure values measured in either arm, angiograms showed complete occlusion of the left subclavian artery at the proximal portion and a moderate stenosis at the distal portion as well as retrograde filling of the left vertebral artery. Following angiography, percutaneous transluminal angioplasty was performed at the occlusive and stenotic portions. Recanalization of the occluded proximal subclavian artery with smooth vessel wall contours and reduction of a stenosis at the distal portion were observed in the postangioplasty angiograms.
It is suggested that percutaneous transluminal angioplasty can be safely applied to occlusive lesions of the left subclavian artery with the retrograde flow of the left vertebral artery.

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A case with brain ischemia induced by the absence of bilateral internal carotid arteries, in which a superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis was performed is reported. No similar case has been reported before.
The patient was a 27-year-old female who had suffered from syncope and right hemiconvulsion since the age of 15. After the first delivery hemiparesis occurred on the right side. The plain skull Xray films including tomograms showed no carotid canal. The aortograms showed a right aortic arch and an aberrant left subclavian artery. The angiograms demonstrated no bifurcation of either common carotid arteries and absence of bilateral internal carotid arteries, except for the cavernous sinus portion and the supraclinoid portion of the right internal carotid artery. The intracranial blood was supplied mainly by the dilated right vertebral artery and the enlarged collateral artery from the right maxillary artery to the cavernous sinus portion of the right internal carotid artery. The supraclinoid portion of the right internal carotid artery was dilated in fusiform. STA-MCA anastomosis was carried out on the left side. Symptoms and the regional cerebral blood flow improved postoperatively.

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Acute and subacute subdural hematomas are commonly associated with brain contusions. These hematomas rarely result from rupture of a cortical artery without evidence of surrounding brain contusion. A case in which a spurting cortical artery was verified at the operation is described and possible mechanisms of the arterial rupture are discussed.
An 88-year-old man fell and hit the left side of his head. About 9 hours later, he gradually became drowsy and was comatose on admission 12 hours later. Computerized tomography scan demonstrated findings suggestive of a subdural hematoma in the right temporoparietal region and a small epidural hematoma in the contralateral temporal region. Right craniectomy was carried out on the same day. Evacuation of a large subdural hematoma revealed pulsating bleeding from a cortical branch of the middle cerebral artery. There was no subarachnoid hemorrhage or contusion of the surrounding cortex. The spurting artery was clipped. Postoperatively the patient regained consciousness and underwent cranioplasty 1 month after surgery.

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A 54-year-old house wife was admitted with a slowly enlarging pulsating mass in the right neck, which became 12×6×6 cm in size within 6 months. Neurological examination revealed a hoarseness and slightly increased deep tendon reflexes of the left upper extremity but no other abnormalities. The right pharyngeal wall was markedly swollen and pulsating. Laboratory tests were all non-contributory and carotid angiography demonstrated a large aneurysmal dilatation of the right internal carotid artery. Right cerebral circulation was diminished due to poor cross filling from the left carotid system and was partly covered by posterior circulation. Surgery was performed under moderate hypothermia and the aneurysm was totally resected using vein graft. Although the immediate postoperative course was uneventful, the patient developed massive edematous swelling of the right cerebral hemisphere at the 3rd postoperative day and succumbed to the diffuse cerebral infarction. Embolic obstruction of the middle cerebral branches was suggested from the postoperative angiography, in which the vein graft showed satisfactory patency.
Histological examination of the resected aneurysm showed advanced medial and partly intimal necrosis, although there was no ulceration of the aneurysmal wall. Only three cases of extracranial carotid aneurysm due to cystic medial necrosis were collected from the literature and surgical hazard of radical resection is discussed with a view of preventing postoperative cerebral infarction.

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Dermoid cysts, or congenital inclusion cysts, of the anterior fontanel have been found in various races. However, the occurrence of such cysts seems to be rare in Japanese. This is the seventh reported case from Japan.
This 10-month-old Japanese girl was the product of a normal pregnancy and delivery. At the age of 3 months, a small mass was noted over the vertex of the head which gradually increased in size. She was referred for surgical treatment. There was a round, soft, non-tender mass located over the anterior fontanel, measuring 2.3×2.3×0.5 cm. It was covered with intact skin and was transilluminating. Neurological examination revealed no abnormality. Skull roentgenograms showed a soft tissue mass over the widely opened anterior fontanel. Computerized tomography scan demonstrated an extracranial cystic lesion of heterogeneous density, which was not enhanced by intravenous contrast medium. No intracranial extension was revealed.
The lesion was removed radically through a curvilinear incision from beneath the periosteum. There was no intracranial connection. The cyst contained approximately 0.8 ml of clear and colorless fluid and caseous material. On histological examination, the wall was composed of stratified squamous epithelium supported by collageneous tissue. Hair follicles, and sebaceous and sweat glands were identified. There was no evidence of malignancy.

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