Photoradiation therapy (PRT) is a recently introduced treatment for malignant neoplasms which depends on tumor localization and retention of hematoporphyrin derivative (HpD) activated by a proper light in the presence of oxygen. The effect of PRT was investigated in vitro and in vivo using rat brain tumor (Tumor 9: T9) induced by N-methylnitrosourea. Argon-pumped dye laser at 630 nm was utilized to provide the activating beam. HpD (0, 5, 10, 50 μg/ml in concentration) was kept in contact with 5×10⁵ T9 cells for 2 hours at 5% CO₂, 37°C in dark. Then the cells were washed twice and laser irradiation using argon-pumped dye laser 50, 100, 150, and 200 mW in power was carried out. The treated cell death was determined by the dye exclusion method with trypan blue. A brain tumor model was developed by in vivo inoculation of 10^5-6 T9 cells in the right parietal lobe of Fisher 344 male rats. On day 14, 20 mg/kg of HpD was given intraperitoneally. On day 17, optical fiber from the laser was inserted stereotaxically through the previous burr hole with the same method as tumor inoculation, and PRT using laser 150 mW in power was carried out. Mean survival times of the PRT group, HpD alone group, laser alone group, and control group were compared. PRT effectively killed T9 cells in culture depending on HpD concentration and power of laser. The mean survival time of the control group and PRT group was 28.18±2.95 days (n=39) and 41.0±7.97 days (n=4), respectively (p<0.01). However, considerable brain edema was induced.

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A new technique for anastomosis of the superficial temporal-middle cerebral arteries (STA-MCA) is described. It uses a single newly designed angled clip to close the recipient artery during anastomosis.
Fifty two recipient arteries in 10 cerebral hemispheres of cadavers were selected from the perisylvian area by microanatomical survey. Each was at least 10 mm in length and more than 0.8 mm in diameter. Each artery was examined for 1) the external diameter, 2) the number and the diameter of its branches, 3) the number of branches to be cut in anastomosis by using the ordinary two clips or the new single clip, and 4) the territory of the collateral circulation from the central artery as examined by India ink injection study. The average diameter was 1.15±0.1 mm. The arteries had on average five cortical penetrating arteries; 45.3% of the branches were up to 0.2 mm in diameter while those of over 0.4 mm were less than 5.5%. The temporo-occipital artery was largest in diameter, but it had a large number of big branches (13%). By the ordinary method, all branches would have had to be cauterized and cut off. But 77% of the 52 arteries did not need to have any branches cut off during anastomosis when the new method was employed. Collateral circulation from the central artery to the anterior cerebral artery via the cortical lepto-meningeal anastomosis was shown by India ink injection study. Disconnection of the branches by using bipolar coagulation during anastomosis may cause some damage not only to the arterial wall and the brain, but also to such a lepto-meningeal anastomosis. The new single temporary clip method has certain advantages in bypass surgery. The first advantage is preservation of the cortical penetrating arteries and the collateral network, the second is the shortening of the operation time, and the third is the capability of performing anastomosis on the functional area or severe ischemic brain.
Seven clinical cases were operated on using this technique. Only 3 of 24 branches in 7 cortical arteries needed to be cut. The recipient artery was the central artery in 3 cases, the precentral artery in 2 cases and the prefrontal artery in 2 cases. All the cases had uneventful operations and postoperative courses. So it can be said that this is a very simple and useful method in bypass surgery.

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Selective external carotid angiography using Seldinger's technique was employed in 20 cases (9 tumors, 9 spontaneous carotid-cavernous fistulas [CCF], 2 others), and its clinical applications are discussed. Diagrams of normal external carotid angiogram were drawn on the basis of analysis of the films obtained from these 20 cases.
Various clinical situations were then investigated as follows: 1) A case with a right temporal bone tumor, where the ophthalmic artery originated solely from the middle meningeal artery of the same side and fed the tumor. 2) Nine cases of spontaneous CCF. One case was an internal CCF, and eight were dural CCF. A case of dural CCF with feeders arising from the accessory meningeal artery, the artery of the foramen rotundum, vidian artery of the external carotid artery, as well as the C₄ part of the internal carotid artery, is presented. 3) A case of left sphenoid ridge meningioma with extracranial extension via the base of the cranium. The proximal part of the external carotid artery was ligated. By vertebral and deep cervical angiographies, the external carotid artery was opacificated via the enlarged anastomoses between the occipital, vertebral, and deep cervical arteries. 4) A case of giant neurinoma in the right middle fossa with a feeder arising from the middle meningeal artery of the same side. Other lesions in the cranium, the face, and the scalp are also presented.
Selective external carotid angiography proved valuable in the diagnosis of the extra and intracranial lesions.

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It is a problem of great concern to prevent ocular toxicity from complicating intra-carotid administration of lipophil anticancer agents. Attempts to prevent such a side effect were made during intra-carotid chemotherapy using remodeled catheter tips for epidural anesthesia. Twenty nine patients with malignant glioma received intra-carotid administration of neocarzinostatin (NCS).
Six out of 17 patients (35.3%) who received intra-carotid perfusion through an original catheter without a remodeled tip, developed ocular toxicity. The catheter tip remained proximal to the ophthalmic artery in all cases. On the other hand, 12 patients with a remodeled catheter tip did not develop ocular toxicity. In the latter group the tip of the catheter was located in the internal carotid artery sufficiently distal to the ophthalmic artery, or beyond the carotid bifurcation in 3 cases. Another advantage of the remodeled catheter was that the intra-carotid perfusion was feasible for a longer period with higher doses of NCS, than treatment with the commercial catheter for superselective embolization, which was found to be easily occluded and often ejected out of the carotid artery. Prior to and during the intra-carotid perfusion selective injection of Angiografin® was performed through the catheter and the tumor was enhanced in the area of arterial supply, indicating the extent of chemotherapy and the degree of destruction of the blood-brain barrier.

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The authors present the results of intra-tumoral chemotherapy as a maintenance therapy for malignant glioma after remission induction therapy. The treatment was repetitive local administration of neocarzinostatin (NCS) into the tumor cavity through Ommaya's reservoir. Five of 6 treated cases survived over 1 year, and the other case expired 10 months after the therapy due to brain stem dissemination of the glioma, although the primary tumor was reduced in size on computed tomography (CT). Three out of 5 patients who survived over 1 year expired within 2 years, due to regrowth of the residual tumor in 2 cases and pneumonia in the third. One case has lived over 4 years. The good candidate for the intra-tumoral local chemotherapy was a patient with a singlecavity tumor and little residual tumor on CT. Histological examination using fluorescence micrograph showed that the fluorescein-labeled NCS had diffused into the tumor through the wall of the tumor cavity over 5 mm. Vacuolar degeneration and necrosis of the tumor cells and hyalinoid degeneration of the tumor vessels were the most characteristic findings. Side effects such as convulsion, hemiparesis or progression of cerebral edema on CT were not noted, but intra-tumoral hemorrhage was seen in one patient, who received about 100 μg NCS in one shot. Cytological examination of the liquid content of the tumor cavity during the treatment showed abundant macrophages with destroyed tumor cells. NCS was found to be the more effective drug not only as an anti-cancer agent, but also as an immunotherapeutic agent.

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Thirty-four patients with medulloblastoma treated between 1967 and 1983 are reviewed. There were 28 infants and children, and 6 adults. Four patients died within 6 weeks after surgery, and the operative mortality rate was 12%. In infants and children the overall survival rate from the time of tumor resection was 39% at 3 years, and unchanged at 5 years. In adults it was 67% and 50%, respectively. There was no difference in survival rates between male and female patients. Eighteen cases showed recurrence. The types of recurrence were as follows: meningeal dissemination, 72%; local regrowth, 22%; bone metastasis, 6%. Seventy-four percent of the patients with meningeal dissemination died within one year after the appearance of clinical manifestations. There was no relationship between the dissemination and the presence of posterior fossa tumor. Posterior fossa tumors were considerably controlled by a radiation dose of 50 Gy. Therefore it was considered that initial whole central nervous system irradiation was one of the most important prognostic factors. Before 1980 radiation doses to the whole spine were 26.7 Gy on the average. Patients were in a supine position during whole brain and posterior fossa irradiation and in prone position only during whole spinal radiation. After 1980 patients were fixed in prone position during the whole irradiation course, and an increased radiation dose to the whole spine (average 31.4 Gy) was applied. Furthermore, the whole brain and spinal cord were irradiated simultaneously for a few days to prevent the migration of tumor cells. Nine children with medulloblastoma were treated after 1980 and none of them showed meningeal dissemination. Among those nine cases there were two recurrences. Local regrowth developed in spite of radical removal of the tumor in one case and systemic bone metastasis in the other.
These are problems which remain in treatment of medulloblastoma. Therapy for meningeal dissemination is usually difficult because of the late appearance of clinical manifestations. The role of cerebrospinal fluid polyamines in the early detection of dissemination is briefly discussed.

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The authors report experiences of anterior cervical discectomy without fusion for cervical disc disease. A series of 17 patients were operated on using a modified Smith-Robinson technique. Radical discectomy and extensive removal of posterior osteophytes were performed without bone graft. Fifteen out of the 17 cases were operated on at a single level. Three discectomies were performed at C4/5, eight at C5/6, and four at C6/7. Two patients had discectomies at two levels (C4/5 and C5/6) during a single surgical procedure. The results were postoperatively evaluated both clinically and radiologically. Immediately following operation, decrease in the height of the operated disc space was recognized in all patients. The collapse of the anterior part of the interspace was prominent at the C4/5 and C5/6 levels. Three of the 17 cases (18%) showed the upper vertebrae slipping backward against the lower vertebrae. However, further progress was not observed. The patients were followed-up for from 6 months to 6 years after surgery. All patients improved postoperatively. Of the 13 patients with radiculomyelopathy, all were considered to have excellent surgical outcomes. No patients had significant postoperative complications. Because discectomy without fusion can simplify the operation and avoid the complications associated with bone grafts, it is considered to be an excellent surgical technique. The authors recommend anterior discectomy without fusion for cervical disc disease at one or two levels, except in cases with spondylosis and unstable spine.

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Osteochondroma is the most common type of benign bone tumor, but it rarely affects the spine.
The patient, a 43-year-old female, was admitted with a 4-year history of slowly-progressive paraparesis and sensory disturbance. Spinal X-ray films and myelography showed an epidural mass and enlarged pedicle of the third thoracic vertebra. Computed tomography (CT) scans of this lesion presented characteristic features compatible with osteochondroma. This diagnosis was confirmed by surgery and by histological study of the resected specimen.
The case presented here, as well as a review of the pertinent literature, suggests that the following CT findings may be typical characteristics of spinal osteochondroma causing spinal compression: 1) a sharply outlined, bone-like density mass projecting into the spinal canal, 2) widening of the vertebral arch or the vertebral body from which the mass projects, 3) continuity of bony cortex of the lesion and that of the adjacent normal bone. The foregoing indicates the value of CT examination in the diagnosis of spinal osteochondroma.

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A case of thrombosis of the dural sinus resulting in hydrocephalus is reported. This 60-year-old female had suffered from chronic right otitis media for 40 years. Recently she suddenly developed headache, vertigo and vomiting. The otitis media was treated surgically and with antibiotics. Thrombosis of the right sigmoid sinus was found at the time of operation. Headache persisted after the operation. Postoperative computed tomography (CT) scan showed ventricular dilatation and periventricular lucency. Cerebral angiography revealed stenosis of the superior sagittal sinus, the straight sinus, the right lateral sinus, and the right sigmoid sinus. After a ventriculo-peritoneal shunt operation, her symptoms and hydrocephalus were alleviated. It was suggested that hydrocephalus in this case was induced by sinus hypertension associated with dural sinus thrombosis secondary to recurrent otitis media. This phenomenon is known to occur usually in infants, but rarely in adults. Possible mechanisms accounting for the development of hydrocephalus secondary to sinus hypertension are discussed.

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A rare case of a surgically verified parasellar neurinoma in a child is presented. The patient, a 10-year-old girl, noticed congestion of the conjunctiva of the left side 2 months prior to admission. A left sixth nerve palsy was pointed out by an ophthalmologist. The results of a neurological examination on admission were otherwise normal. A computed tomogram showed a round parasellar mass on the left side. The tumor was heterogeneously hypodense and showed a marked, homogeneous enhancement. Carotid angiography revealed tiny abnormal vessels originating from the middle meningeal artery. At operation, a solid tumor lying under the dura mater was found. It lay medially and anteriorly to Meckel's cavity, in contiguity with the cavernous sinus. Nerves IV, V, and VI were not visible even after total dissection of the tumor, and the connections to these nerves were not revealed. Histologically, the tumor was a neurinoma of the Antoni type A. The patient was discharged 3 weeks after operation with a full recovery except for a slight diplopia.
In this case the exact origin of the neurinoma could not be identified even with the use of an operating microscope. The fact that the sixth nerve palsy disappeared in a short time after removal of the tumor may suggest that the tumor did not originate from the sixth nerve. Consequently it is thought that a sensory or vasomotor nerve distributed in the dura mater may be the site of the tumor origin.

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A case of a 12-year-old boy with primary intracranial endodermal sinus tumor with spinal and posterior fossa metastases is presented, with sequential changes of radiological findings and alphafetoprotein levels during the clinical course.
Reported cases of intracranial endodermal sinus tumor with metastases of the spinal cord and other regions, and those with good results and long survival without spinal metastasis, are compared from the therapeutic point of view. Radiosensitivity of the tumor and the value of preventive spinal irradiation is discussed. It can be concluded that surgical extirpation of the tumor for histological confirmation, radiation therapy with or without spinal irradiation, and adjuvant chemotherapy are the treatment of choice for malignant germ cell tumors.

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A case of acute subdural hematoma immediately after surgical intervention for the contralateral chronic subdural hematoma in a regularly hemodialyzed patient is reported. A 59-year-old male was admitted because of progressive right hemiparesis after six years of regular hemodialysis. A computed tomography (CT) scan revealed typical left chronic subdural hematoma. Irrigation and drainage of the hematoma through a single burr hole was performed. The right hemiparesis was improved after surgery and a CT scan two hours after surgery revealed a marked reduction of the hematoma cavity. However, the patient suddenly became comatose eight hours after surgery, and another CT scan showed a contralateral acute subdural hematoma. The patient expired the following morning. Postmortem pathologic examination showed an old left subdural hematoma membrane and a massive subdural hematoma without any membrane in the right fronto-temporal area. Subdural hematoma has a higher mortality rate among hemodialysis patients than in the normal population, and many authors have reported disappointing results of surgical intervention in such cases. This case suggests that the high frequency of subdural hematoma can be attributed to the accompanying coagulopathy and the acute decrease of intracranial pressure. The authors emphasize careful management including peritoneal dialysis before and after the surgical intervention.

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