Digitally controlled ultrasonography using a 5-MHz mini-sized, sector-scanning probe was performed in 21 cases of craniotomy, in 22 cases of burr-hole opening, and in 2 cases of laminectomy. The probe could be sterilized. The tip of the probe measured 17.8×19.6 mm. Among craniotomy cases, one small pituitary adenoma case and two small berry aneurysm cases failed visualization. Another adenoma and a large aneurysm were imaged. Ultrasound was helpful in 11 cases (52%), and most of them were supratentorial intraparenchymal masses, such as gliomas and intracerebral clots. In 5 of them puncture and/or biopsy was successfully performed under ultrasonic monitoring: 2 manually and 3 using a needle-guide apparatus and a guideline superimposed on the cathode-ray tube image. Maneuverability of the biopsy needle or forceps could be controlled, and no hemorrhage was encountered. The burr-holes were mostly conically enlarged using a Hudson No. 3 drill. Sterile echo-jelly was placed in the gap between the probe tip and the dural surface. Two targets were not visualized; one was an aneurysm and the other a cavernous sinus tumor. In 2 ventricular tappings through the hole, ultrasound showed both the direction and the depth of the target. In a case of brain abscess, two burr-holes were placed so that an ultrasonically monitored puncture could be performed using the needle-guide apparatus. The needle tip position could be adjusted accordingly with the gradual shrinkage of the capsule by aspiration. In 2 cases of laminectomy, the normal subarachnoid space was clearly exhibited. In a total of five cases, ultrasound was found not only helpful but in fact indispensable. However, several imperfections were noted: First, areas close to the probe could hardly be seen due to the near-field artifact. Second, the thickness of the ultrasonic beam limited image resolution in its direction. Third, the size of the probe was still larger than the diameter of a burr-hole. Finally, there were still image artifacts due to the sidelobe, reverberation, and acoustic enhancement, especially when metallic material was introduced into the ultrasonic field. In conclusion, electronic sector-scanning ultrasonography should become an indispensable tool in the neurosurgical operating theater in the near future.

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Radiotherapy combined with bleomycin, ACNU, and vincristine was performed on 106 patients with malignant brain tumors. The treatment protocol was based on the concept of combination chemotherapy or chemoradiotherapy and synchronized chemoradiotherapy. For the purpose of synchronized chemoradiotherapy, bleomycin, ACNU, and vincristine were used as G²M cell cycle phase accumulator, and radiation and bleomycin were used as agents to which G²M or G² phase cells are sensitive. The short-term results of the chemoradiotherapy were evaluated by measuring tumor regression by computerized tomography (CT) in 80 patients with evaluable CT lesions.
The response rate (complete response+ partial response) was 67% (6/9) for astrocytoma, 29% (7/24) for anaplastic glioma, 67% (4/6) for pontine glioma, 100% (5/5) for malignant lymphoma, 100% (8/8) for germ cell tumors and 65% (15/23) for metastatic tumors. A control study was performed using radiation alone on another 18 patients with metastatic tumors, and the response rate was 50% (9/18). Among the 106 patients treated with chemoradiotherapy, the major side effects observed were as follows: leucopenia in 33 patients (31 %), thrombocytopenia in 14 (13%), paralytic ileus in 2 (2%), peripheral neuropathy in 2 (2%), and lung fibrosis in 1 (1 %). Contrary to expectation, low-grade astrocytomas responded much better to the chemoradiotherapy than high-grade astrocytomas. Chemoradiotherapy seems to be more effective in causing regression of malignant brain tumors than radiation alone, but further studies on the long-term results of this treatment are necessary.

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Cerebral blood flow (CBF) is usually decreased in patients with hypertensive intracrebral hemorrhage.
A total of 81 regional CBF measurements were performed using an Anger-type dynamic gamma camera with the Xe-133 intracarotid injection technique in 23 patients with thalamic hemorrhage, 18 with small putaminal hemorrhage, and 5 with large putaminal hemorrhage.
The results were as follows: Bilateral CBF in thalamic hemorrhages was markedly reduced from 1 week to 2 or 3 weeks after onset; it then showed a tendency to increase from 4 weeks to 3 months. In putaminal hemorrhages, however, CBF in the affected hemisphere did not tend to increase despite increased CBF in the contralateral hemisphere. CBF of the affected hemisphere was plotted against the hematoma volume, and the biphasic curve showed an initial steep and subsequent gentle slope in both putaminal and thalamic hemorrhages. The degree of CBF reduction in the affected hemisphere was more evident in thalamic than in putaminal hemorrhages. However, the flow reduction in the contralateral hemisphere was more obvious in thalamic than in putaminal hemorrhages. Factors such as mean arterial blood pressure, partial pressure of arterial carbon dioxide, cerebrospinal fluid pressure, hematocrit and the degree of involvement of the internal capsule, as shown on CT scan were not directly related to CBF reduction.
In conclusion, it is unlikely that the mass effect of the hematoma plays an important role in the discrepancy between CBF reduction in putaminal and thalamic hemorrhages. Rather, the discrepancy may result from the impairment of respective anatomical sites in the thalamic and putaminal regions. It is also suggested that ipsilateral as well as contralateral CBF reduction is probably caused by the decreased cortical metabolic demand. This may be based on the disruption of the transneural fiber pathways, which connect both the thalamus and putamen to the cerebral cortex.

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Twenty-one cases of ruptured middle cerebral artery aneurysm with intracerebral hematoma were studied. The age distribution ranged from 16 to 68, with an average of 48 years. Fifteen were female, 6 male. Computerized tomography (CT) scans were performed within 24 hours after the onset in 19. Diagnosis was established by angiography or surgery. Seventeen patients were operated on, whereas 4 were not because their condition was too poor. CT showed hematoma in the Sylvian fissure and the temporal lobe in a section 30 mm above the orbitomeatal line. Extension of the hematoma was to the frontal lobe anteriorly and/or the temporal lobe posterosuperiorly. The site of hematoma was related to the direction of the aneurysmal projection. Cases were divided into the following three groups: Group I; cases with the temporal lobe hematoma. Group II; cases with hematoma extending to both the frontal and temporal lobes. Group III; cases with hematoma in the frontal lobe. All of the 14 cases in Group I underwent operation. Mortality was 14%. Morbidity was correlated to the size of hematoma. The outcome was good in cases with hematoma less than 40 mm in diameter. Four out of 6 cases of Group II were not operated on and died within 3 days after onset. Uncal herniation was suspected early in their course. Of two operated cases, one died and the other was severely disabled. Outcome in one case of Group III was good. This study suggests that outcome can be anticipated from CT findings.

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Of 344 patients with intracranial aneurysms treated at the Shimane Medical University and Matsue Red Cross Hospital, eighteen (5.2%) had aneurysms of the distal anterior cerebral artery (DACA). Five were male and thirteen were female. Their ages ranged from 39 to 67 years. Seventeen patients had had at least one episode of subarachnoid hemorrhage (SAH) caused by rupture of the aneurysm of DACA. Motor disturbance found in 8 cases was a rather specific clinical feature on admission. There were 4 cases with hemiparesis predominant in the lower limb, 3 with monoparesis of a leg, and 1 with tetraparesis. Six of the aneurysms were located at the bifurcation of the pericallosal artery (PCA) and callosomarginal artery, 6 at the bifurcation of PCA and anterior internal frontal artery, 3 at the distal end of azygos anterior cerebral artery (ACA), and 3 on the peripheral PCA. Eleven aneurysms were on the left side, 4 on the right, and 3 on the midline. Six patients were shown to have multiple aneurysms. Azygos ACA was noted in 3 cases and bihemispheric ACA in 2. In 7 cases, PCA made a sharp bend at the genu of the corpus callosum where the aneurysm was located. Computerized tomography (CT) scans were done in 6 cases. Blood was found in the basal cisterns and bilateral Sylvian fissures in symmetrical distribution, and extended into the anterior interhemispheric fissure and pericallosal cistern in all six. Two cases had a large intracerebral hematoma in the corpus callosum. Direct surgical attack on the aneurysm was made in 17 cases. Long-term follow-up results revealed that 10 cases had no neurological deficits, 2 had minimal deficits, 2 were moderately disabled, and 3 died.
From an analysis of these 18 cases and 191 cases reported in the literature, the following results were obtained: 1) The incidence of DACA aneurysm was approximately 5%. There was no difference in sex distribution, and most cases were found in the fifth to sixth decade. 2) Seventy-one percent were located at the pericallosal bifurcation, 15% in the infracallosal portion of PCA, and 6% on the supracallosal portion. Multiple aneurysms were found in 29%. 3) Leg monoparesis and predominantly crural hemiparesis may be rather specific clinical features. 4) Anomalies and anatomical variations of DACA were found, such as azygos ACA, bihemispheric ACA, supreme anterior communicating artery, and acute angulation of PCA at the genu of corpus callosum.

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Treatment of dural arteriovenous malformation (DAVM) has not yet been established. Since 1976, the authors have performed radiation therapy on 12 DAVM cases, consisting of 5 in the cavernous portion and 7 in the posterior fossa area. Extraaxial irradiation of ⁶⁰Co, 100-200 rad, 2-3 times per week was focused on the nidus of DAVM and on the angiomatous abnormal vascular network. Total doses of ⁶⁰Co irradiation ranged from 1, 000 to 10, 000 rad, with a mean value of 4, 700 rad. In 11 cases out of 12, DAVM disappeared completely, as proved by angiography. The other case refused angiography and the disappearance of DAVM could not be proved. Outcome was good compared to untreated cases or cases treated by other methods. Complete disappearance of DAVM began 1 to 14 months after irradiation. The post-irradiational observation period was from 16 months to 6 years 10 months. Side effects such as radiation necrosis, occlusion of the main arterial trunk, occlusion of the venous sinus, visual or optic nerve disturbance, and appearance of meningioma did not occur in this series. Radiation therapy was considered to be effective and to produce minimal adverse effects. It should be considered the first choice in the treatment of DAVM.

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The authors report 2 cases of venous angioma of the posterior fossa, an uncommon disorder. Case 1: A 17-year-old boy was admitted complaining of dizziness, headache, and vomiting. Neurological examination disclosed conjugate deviation to the right, left-sided limb and truncal ataxia, gait disturbance, and dysarthria. Plain computerized tomography (CT) showed a highdensity area indicating a hematoma in the left cerebellum. Enhanced CT showed a linear enhancement inside the hematoma, probably corresponding to a dilated draining vein. Vertebral angiography revealed a venous angioma in the early venous phase that was drained into a dilated precentral cerebellar vein. Case 2: A 33-year-old female was admitted complaining of nausea, vomiting, and vertigo. Neurological examination disclosed dysarthria, right-sided limb and truncal ataxia, and Bruns nystagmus. Plain CT showed a high-density area indicating a hematoma in the right cerebellum. Enhanced CT showed a nodular enhancement inside the hematoma, probably corresponding to a dilated draining vein. Vertebral angiography revealed a venous angioma in the early venous phase that was drained into a dilated inferior hemispheric vein. Surgical removal of the angioma was successfully performed in both cases. Radical operation is recommended in cases of hematoma because the frequency of rebleeding is high.

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Forty-nine cases of chronic subdural hematoma experienced during the past 5 years were analyzed as to the number of days elapsed following head injury, symptoms, and computerized tomography (CT) findings. As a result, the clinical course of chronic subdural hematoma was devided into the following 5 stages on the basis of the presumed pathologic processes.
The initial stage corresponded to a period of about 2 weeks after the precipitating injury; symptoms were absent; plain CT showed low-density areas (LDA) ; and metrizamide CT revealed metrizamide penetration into the LDA. The premature stage corresponded to a period of 2-4 weeks after trauma; no symptoms were present; plain CT showed LDA; and metrizamide CT revealed that metrizamide penetrated into the LDA with difficulty. The mature stage corresponded to a period of 30-60 days after trauma; CT showed iso-density areas (IDA) or high-density areas (HDA) with occasional enhancement effect; metrizamide penetration was not detected; and symptoms such as headache may have been present. The progressive stage typified chronic subdural hematoma; headache and focal symptoms were present; plain CT showed relative LDA, IDA, HDA or mixed-density areas (MDA) ; and enhancement of the contents of hematoma was observed in roughly half of the cases. The resolving stage was the stage in which hematoma had disappeared; plain CT showed relative LDA or LDA without mass sign; and metrizamide penetration was not detected. This clinical staging was useful in evaluating the pathologic picture of the chronic subdural hematoma and in determining suitable treatment.

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Four hundred two cases of blunt head injury admitted to Chikamori Hospital during the period from January 1980 through May 1983 were examined by plain craniogram and computerized tomography (CT) scan on admission. Skull fracture was observed in 82 (62%) of 132 child cases and in 162 (60%) of 270 adult cases. Intracranial complications were observed in 29 (22%) child cases and in 135 (50%) adult cases. They were classified according to CT findings as follows: 1) epidural hematoma, 2) subdural hematoma, 3) intracerebral hematoma and brain contusion, 4) subarachnoid hemorrhage, and 5) diffuse cerebral swelling or normal.
Parenchymal lesions, which constituted the most important factor in predicting outcome, were observed in 15 (52%) of 29 child cases and in 107 (79%) of 135 adult cases. Brain contusion was observed as a coup lesion in most child cases, but diffuse parenchymal lesion, which was related to rotational acceleration, was demonstrated in severely injured cases. In adult cases, brain contusion was observed in the frontal base and the temporal tip with sagittal impact, and in the bilateral frontal base and temporal lobes with lateral impact. So-called delayed traumatic intracerebral hematoma appeared in the frontal and temporal lobes. Extraparenchymal hematoma was found on the side of impact in child cases, whereas subdural hematoma in adults was more frequent on the contralateral side.
In conclusion, skull fracture shows the point, direction, and amount of impact, suggesting the mechanical background of the injury and predicting the parenchymal lesion as well as extraparenchymal hematoma.

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A case of resolved chronic subdural hematoma associated with acute subdural hematoma in moyamoya disease is reported. This 57-year-old housewife was hospitalized in 1983, because of the sudden onset of unconsciousness and vomiting. The patient had been in good health until 1963, when she had the first attack of vertigo and headache. Similar attacks recurred in 1965, 1973, and 1975. One year before admission she had suffered recurrent vertigo and ataxia. On admission she was semicomatose without focal neurological signs. Computerized tomography (CT) scan revealed a subdural hematoma in the left frontoparietal region with a low-density layer on its outer side. Cerebral angiography disclosed narrowing of the bilateral internal carotid arteries with moyamoya networks in the area of the basal ganglia. Emergent left craniotomy was performed to find the subdural hematoma with the resolved chronic subdural hematoma. Bleeding from a transdural cortical anastomosis of the middle meningeal artery was found in the parietal area and was coagulated. The postoperative course was uneventful except for mild right hemiparesis and motor aphasia.
The mechanism involved in the development of subdural hematoma due to rupture of transdural cortical anastomosis in moyamoya disease is discussed.

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A case of intracranial cryptococcal granuloma accompanied by cerebral aneurysm is reported.
A 32-year-old woman was admitted complaining of grand mal seizures which had begun one year before. There were no specific neurological findings. Brain computerized tomography (CT) scan showed an iso-density area in the left frontal area, which was surrounded by a small low-density area enhanced homogeneously by intravenous injection of contrast medium. Left carotid angiogram disclosed an unruptured aneurysm in the C₂ portion. ^99mTc-DTPA brain scan showed an abnormal isotope accumulation in the left frontal area. Cerebrospinal fluid was normal. Neck clipping of the aneurysm and total removal of the tumor were uneventful. Pathologically, the tumor proved to be a cryptococcal granuloma.
Intracranial cryptococcal granuloma is rare. Only 13 cases in which CT findings were reported could be found in the literature.

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Occurrence of multiple intracranial arteriovenous malformations (AVM) in one patient is extremely rare. A 72-year-old woman was admitted with a sudden onset of severe headache, vomiting, right hemiparesis, lethargy, and motor aphasia. Computerized tomography (CT) scan showed a small left temporal subcortical hematoma. Angiography revealed a dural AVM near the left lateral dural sinus, fed by the left occipital and left posterior auricular arteries. The left lateral sinus was seen occluded, and the venous drainage consisted of the vein of Labbe and the left sphenoparietal sinus. Three weeks later, the patient gradually became comatose, and repeat CT scan showed enlargement of the hematoma, surrounded by a low-density area. Emergency evacuation of the hematoma was performed. A small mass easily prone to bleeding was found on the wall of the hematoma cavity. Microscopic examination revealed cryptic vascular malformation.
The mechanism of intracerebral hemorrhage in this patient was noteworthy. Rupture of the cryptic vascular malformation was the cause of the hematoma. Highly elevated venous pressure alone can cause such a rupture. The elevated venous pressure in the left temporal lobe was the result of retrograde flow via the vein of Labbe and the ipsilateral transverse sinus occlusion.

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