Neurologia medico-chirurgica

Flow Patterns at the Bifurcation and Curving Portion of the Human Middle Cerebral Artery

With Reference to the Localization of Atherogenesis

Shoji MABUCHI, Hiroshi ABE, Takeshi KARINO

1988 Volume 28 Issue 4 Pages 321-326
Published: 1988
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.28.321

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The relationship between blood flow and the localized development of atherosclerosis and thrombosis were studied at the bifurcation and curving portion of a human cerebral artery. Blood flow patterns were studied by direct observation and by photographing of tracer particles flowing through the isolated arterial segment, which had been obtained at the time of death and had been prepared in such a way that it was transparent. A standing recirculation zone consisting of a pair of secondary flow spirals, located on both sides of the common median plane of the bifurcation, was formed on the lateral side of the daughter vessels over wide ranges of inflow Reynolds numbers (Re₀) and flow rate ratios (Q₁: Q₀; Q₀ and Q₁ indicating the quantity of flow in M₁ and M₂ segment of the middle cerebral artery, respectively). The formation and size of the recirculation zone were largely dependent on Q₁: Q₀ and Re₀. In addition, formation of eddies was observed on the inner side of the curving portion as well as at the bifurcation of the middle cerebral artery.
The results suggest that, under physiological conditions, there is a standing recirculation zone in the bifurcation and bending portion of the middle cerebral artery, which affects local mass transfer and interactions between blood cells and the vessel wall. This may contribute to the development of atherosclerosis and thrombosis in this and anatomically similar regions.

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Cerebral Hemodynamics in Moyamoya Disease

Recovery of Cerebral Blood Flow after Hyperventilation

Jun KARASAWA, Haruhiko KIKUCHI, Sen YAMAGATA, Shigekazu TAKEUCHI, Hisa ...

1988 Volume 28 Issue 4 Pages 327-332
Published: 1988
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.28.327

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Rebuild-up phenomenon, an electroencephalographic pathological finding in moyamoya disease, was evaluated in the context of dynamic changes in cerebral circulation after hyperventilation. Sequential functional angiography after hyperventilation, measurement of cerebral blood flow (CBF) by the outflow method, and Kr-81 m single photon emission tomography were employed for clarification of the sequential dynamic changes in cerebral circulation after hyperventilation. In most cases there was a persistent decrease in CBF even after arterial carbon dioxide tension (PaCO₂) had been normalized, which suggests that the response of the cerebral circulation to the changes in PaCO₂ is delayed. Moreover, this feature was most prominent in the superficial layer of the cerebrum. For the most part, coincidence and synchronization were documented between rebuild-up and the delayed response of the cerebral circulation. These findings indicate that the delayed CBF response to hyperventilation contributes pathogenetically to rebuild-up in moyamoya disease.

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Cerebral Blood Flow as a Prognostic Indication in Subarachnoid Hemorrhage

Sen YAMAGATA, Haruhiko KIKUCHI, Ikuo IHARA, Izumi NAGATA, Yoshito MORO ...

1988 Volume 28 Issue 4 Pages 333-339
Published: 1988
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.28.333

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In an investigation of the changes in cerebral blood flow (CBF) in subarachnoid hemorrhage, CBF was monitored in 14 patients who underwent surgery within 3 days of the onset of hemorrhage. On admission, one patient was neurological grade I, one was grade II, seven were grade III, and five were grade IV. Computed tomography showed diffuse, thick subarachnoid hemorrhage with or without intracerebral hematoma in all patients, strongly indicating the possibility of cerebral vasospasm. CBF monitoring was performed by the thermal diffusion technique, in which a small flow probe, 7 mm in diameter and 4 mm in height and containing a Peltier stack, is used. The probe was implanted in the subdural space in the frontotemporal region during surgery. Epidural intracranial pressure was also monitored. Local CBF was measured continuously for 7 to 19 days after surgery. Immediately after surgery, CBF was low in grade IV patients (mean, 25 ml/100 g/min), whereas a variety of CBF rates were observed in grade III patients. Minimal decreases in CBF were noted in the grades I and II patients (mean, 41 ml/100 g/min). The sequential changes in CBF were well correlated with outcome. The two grades I and II patients, who had no appreciable decrease in CBF, had excellent outcomes. In the five (of seven) grade III patients who showed good or excellent recovery, CBF was maintained with only a slight decrease. In two grade III patients, substantial depression of CBF occurred several days after the onset of subarachnoid hemorrhage; one had a poor outcome, and one died. Good recovery of CBF was observed in one grade IV patient, who showed excellent postoperative recovery. The remaining four patients, had moderate to substantial decreases in CBF, with poor postoperative results, including two deaths. These observations indicate that a decrease in CBF due to vasospasm or other causes can be detected early through CBF monitoring. In addition, the outcome of subarachnoid hemorrhage can be predicted on the basis of sequential changes in CBF.

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Cortical Arterial Pressure and Anastomotic Blood Flow Measurements during STA-MCA Anastomosi

Takeshi SHIMA, Yoshikazu OKADA, Shigejiro MATSUMURA, Masahiro NISHIDA, ...

1988 Volume 28 Issue 4 Pages 340-345
Published: 1988
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.28.340

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Superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis was performed in 72 patients with internal carotid artery (ICA) occlusion (22), ICA stenosis (25), middle cerebral artery (MCA) occlusion (eight), MCA stenosis (eight), or moyamoya disease (nine). Cortical arterial pressure (CAP) was obtained as a back pressure by temporary occlusion of the STA trunk after STA-MCA anastomosis. Anastomotic blood flow (AF) was measured with an electromagnetic flow meter applied to the STA. Systemic arterial blood pressure (SABP) was measured at the radial artery. The size of the STA was measured at the anastomotic site by the use of preoperative angiography. The mean CAP and AF were 45 mmHg and 30 ml/min in ICA occlusion, 83 mmHg and 20 ml/min in ICA stenosis, 36 mmHg and 32 ml/min in MCA occlusion, 72 mmHg and 21 ml/min in MCA stenosis, and 31 mmHg and 31 ml/min in moyamoya disease. The product of perfusion pressure (SABP-CAP) and square of the internal diameter of the STA was significantly correlated with AF. The results of this study suggest that a CAP of 20 to 30 mmHg may be critical in occlusive cerebrovascular diseases. Furthermore, CAP and STA size appear to be the two most important indicators of blood supply through STA-MCA anastomoses.

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Effects of Induced Hypotension and Hypertension on Cortical Arterial Pressure and Anastomotic Blood Flow during STA-MCA Anastomosis

Yoshikazu OKADA, Takeshi SHIMA, Shigejiro MATSUMURA, Masahiro NISHIDA, ...

1988 Volume 28 Issue 4 Pages 346-352
Published: 1988
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.28.346

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The effects of intraoperative induced hypotension and hypertension on cortical arterial pressure (CAP) and anastomotic blood flow (AF) were investigated for determination of the autoregulatory potential in patients who undergo superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis. Hypotension and hypertension were produced by intravenous injection of trimethaphan camsylate and phenylephrine hydrochloride, respectively. The mean CAP, AF, and systemic arterial blood pressure (SABP) were 63 mmHg, 25 ml/min, and 102 mmHg, respectively, on the average. The effects of hypotension and hypertension were analyzed by the ratios of Δmean AF to Δmean SABP and Δmean CAP to Δmean SABP. In induced hypertension, Δmean CAP to Δmean SABP and Δmean AF to Δmean SABP were 0.67±0.40 and 0.21±0.37, respectively. In induced hypotension, Δmean CAP to Amean SABP and Δmean AF to Δmean SABP were 0.59±0.40 and 0.07±0.15, respectively. Eight patients exhibited a failure of autoregulation; their mean CAP, AF, and SABP were 35 mmHg, 37 ml/min, and 95 mmHg, respectively, on the average. These data indicate that autoregulation of STA-MCA anastomotic blood flow is excellent in most cases. In some instances, however, autoregulatory dysfunction was observed, and this no doubt plays an important role in temporary neurological deterioration after STA-MCA anastomosis.

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Postoperative Hemodynamic Changes in Patients with Pituitary Tumors

Masami SHIMODA, Akira IKEDA, Naoki SHIBUYA, Isao YAMAMOTO, Ryuichi TSU ...

1988 Volume 28 Issue 4 Pages 353-359
Published: 1988
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.28.353

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Antidiuretic hormone (ADH) affects both diuresis and pressor functions, and recent studies have shown hemodynamic changes after its administration. The authors studied postoperative hemodynamic changes in 10 patients with pituitary tumors and examined the correlations among diabetes insipidus (DI), serum ADH, biochemical parameters, and hemodynamics. Systemic vascular resistance (SVR) was significantly lower in patients when they are in DI stage than in non-DI stage. On the other hand, the cardiac index (CI) was higher in patients when they are in DI stage. There were no significant differences between the two groups in central venous pressure or pulmonary capillary wedge pressure. Regardless of whether DI was temporary or permanent, the CI increased and SVR decreased immediately after surgery and, within a few days, returned to the preoperative status. These postoperative hemodynamic changes were the same as those routinely encountered after surgery. These results suggest that fluctuation in ADH after transsphenoidal surgery in patients with DI does not cause hemodynamic changes. Such changes are evidently prevented by various physiological autoregulatory mechanisms.

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Long-term Follow-up of EC/IC Bypass

Akihiro TAKAHASHI, Nobuyuki YASUI, Akifumi SUZUKI, Ichiro SAYAMA, Shin ...

1988 Volume 28 Issue 4 Pages 360-366
Published: 1988
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.28.360

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Between 1973 and 1985, superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis was performed in 125 patients with steno-occlusion of the internal carotid or middle cerebral artery. Patients with moyamoya disease were excluded. One hundred twenty patients were followed for an average of 5.1 years (range, 0 to 12.5 years). The patients were divided into four groups according to the degree of neurological deficit. Mild neurological deficit (MiND) was observed in nine patients with transient ischemic attacks, six with reversible ischemic neurological deficits, nine with minor stroke who underwent surgery within 3 weeks of onset, and 37 with minor completed stroke. The moderate neurological deficit (MoND) group consisted of five patients with major stroke who were operated within 3 weeks and 12 with major completed stroke who had incomplete hemiparesis. Among the patients with severe neurological deficit (SND) were seven with major stroke and 19 with major completed stroke and, complete hemiparalysis. The fourth group included 16 patients with acute progressing stroke (APS). The results of follow-up in the MiND group were consistent with those of the International Cooperative Study of Extracranial/Intracranial (EC/IC) Arterial Anastomosis.
Drug-induced electroencephalography and evoked potential test was performed in 60 cases. Hemodynamic competence was confirmed by means of induced hypotension in seven MiND patients, none of whom had further cerebral ischemic attacks. Reversibility of neurological deficits (ischemic penumbra) was demonstrated during induced hypertension in eight cases (two of MiND, three of MoND, and three of APS). In all of these cases the neurological status improved. Cerebral blood flow (CBF) was measured under induced hypotension in 13 cases, and two patients in the MiND group showed reduced CBF and had no further cerebral ischemic attacks. These results suggest that it is essential to document hemodynamic competence and reversibility of functional deficits (ischemic penumbra) in patients being considered for EC/IC bypass.

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Clinicopathological Study of High-dose Fractionated Radiation Therapy in the Treatment of Glioblastoma

Masaru TAMURA, Hiroshi INOUE, Hideo KUNIMINE, Masaru NAKAMURA, Nobuo O ...

1988 Volume 28 Issue 4 Pages 367-372
Published: 1988
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.28.367

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Twenty-six adults with glioblastoma multiforme (grade 4 astrocytoma) were postoperatively given high-dose fractionated radiation therapy (5 Gy twice weekly) with Linac X-rays. The results were compared with those in 26 patients treated by conventional fractionated radiation therapy (2 Gy 5 times weekly). The survival rates following treatment with high-dose fractionated radiation therapy and conventional fractionated radiation therapy were 65% vs. 65% at 1 year, 31% vs. 8% at 2 years, 14% vs. 4% at 3 years, and 4% vs. 0% at 5 years. The difference in length of survival between the two treatment groups was not statistically significant (p = 0.423). Autopsies were performed on 11 patients given high-dose radiation therapy and 13 who received conventional irradiation. In the high-dose group one patient had no residual tumor (vs. none in the conventional group) ; four had small residual tumors (vs. three) ; one had extensive coagulative necrosis of the tumor and surrounding brain tissue (vs. four) ; four had proliferative tumor growth (vs. four) ; and one had mixed glioblastoma and fibrosarcoma (vs. two). Complete cure may be possible in some cases, if extensive tumor removal is feasible and is followed by high-dose fractionated radiation therapy. The biological effect appears to be much greater with high-dose than with conventional fractionated radiation therapy. Therefore, in cases of tumor recurrence, a second course of radiation therapy must be undertaken cautiously.

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Magnetic Resonance Imaging of Spinal Dysraphism

Minoru AKINO, Toyohiko Isu, Yoshinobu IWASAKI, Hiroshi ABE, Satoru ABE ...

1988 Volume 28 Issue 4 Pages 373-379
Published: 1988
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.28.373

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Nineteen patients with lumbosacral spina bifida were studied by magnetic resonance imaging (MRI) and were divided into two groups: those with lumbosacral lipoma and those with meningomyelocele. All of the patients with meningomyelocele underwent surgery soon after birth for closure of the skin defect. Whenever possible, examination was not confined to the lumbosacral area but also included the brain and other portions of the spinal cord. Certain similarities and differences in pathology were ascertained in the two groups. The tethered cords were the same in both groups. However, Chiari malformations were observed only in patients with meningomyelocele, and hydrocephalus occurred only in patients with Chiari malformations. Syringomyelia and scoliosis were detected in both groups, but scoliosis was more prevalent in the meningomyelocele group. There appeared to be a correlation between scoliosis and syringomyelia; in five of the seven cases of syringomyelia, the locations of the scoliosis and syringomyelia were the same. With MRI, these complex pathologies, including tethered cord, syringomyelia, scoliosis, Chiari malformations, and hydrocephalus, were easily visualized. The superiority of MRI over conventional X-ray technology has been well established. First, a direct image of the spinal cord is obtained. Second, there is no necessity for injection of contrast material into the intrathecal space. Third, any scanning field is possible. There are also some disadvantages with MRI. First, the spatial resolution is inferior to that of high-resolution computed tomography. Second, MRI cannot provide information concerning bone cortex. Therefore, bone involvement cannot be accurately diagnosed. However, in the assessment of spinal dysraphism, MRI is an excellent diagnostic tool and should be the preferred method of diagnosing spinal dysraphism.

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Traumatic Intraventricular Hemorrhage

Factors Affecting Outcome in 22 Cases

Makoto MIZUNO, Tadahisa KURIMOTO, Yasuo YAMANOUCHI, Kuniyuki SOMEDA, H ...

1988 Volume 28 Issue 4 Pages 380-386
Published: 1988
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.28.380

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The authors studied 22 cases of traumatic IVH encountered during a recent 5-year period, with particular emphasis on factors related to outcome. There were 21 males and one female ranging in age from 3 to 76 years. These 22 cases constituted 7.2% of all severe head injuries (Types III and IV, according to Araki's classification) seen in the authors' institution during the study period. They were classified into four types on the basis of the CT findings: Type I, IVH with no other intracranial abnormality; Type II, IVH with other intracranial abnormalities; Type III, delayed IVH (after decompressive surgery) ; and Type IV, IVH due to penetration of an intracerebral hematoma. The incidence of Types II and IV IVH was high. The average Glasgow Coma Scale (GCS) score on admission was 7.0, with Type I patients having the lowest mean score (4.3). The direction of impact was most often anteroposterior in Type I and lateral in Type II. Associated intracranial lesions were observed in 95% of the patients. These were mostly brainstem injury in Type I and brain contusion or subdural hematoma in Types II and III. The overall mortality rate was 54.5%. It was 67% in Type I, 50% in Type II, 33% in Type III, and 63% in Type IV. The outcome appeared to have been determined largely by the severity of associated brain injury and the GCS score, which suggests that the severity of impact or brain injury causing the IVH is the most important factor in terms of prognosis.

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Acute Epidural Hematoma: Relationship between Neurological Symptoms and Hematoma Volume

Kiyonobu IKEDA, Haruhide ITO, Hironobu MUKAI, Shinjiro YAMAMOTO

1988 Volume 28 Issue 4 Pages 387-392
Published: 1988
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.28.387

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Patients with acute epidural hematoma (AEH) may develop cerebral dysfunction secondary to compression of normal brain by the extracerebral mass. Fifty-four patients who developed AEH within 3 days of head trauma were studied in terms of the relationship between neurological symptoms and hematoma volume. The hematoma volume was measured by semiautomatic analysis of computed tomographic (CT) scans. The volume V (ml) was roughly estimated by the formula: V=2π (5.5d² d³/3), where 2d (cm) represents the maximum thickness. Disturbance of consciousness and hemiparesis developed as the hematoma volume increased. Beyond 6 hours after trauma, patients with an AEH below 55 ml in volume had little or no disturbance of consciousness, whereas those with an AEH of more than 70 ml had hemiparesis and impaired consciousness with Glasgow Coma Scale scores 12 or less. Descending tentorial herniation was demonstrated by CT in cases where the AEH was greater than 50 ml, and advanced herniation was observed when the AEH exceeded 150 ml. Nearly all of the patients with uncomplicated AEH showed good recovery within 6 months following evacuation of the hematoma; however, those whose hematomas were over 140 ml had poor outcomes.

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Vacuolated (Microcystic) Meningioma

Report of Two Cases

Yasuo SUGITA, Seiichi KOBAYASHI, Yasuhiro YOSHITAKE, Minoru SHIGEMORI, ...

1988 Volume 28 Issue 4 Pages 393-397
Published: 1988
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.28.393

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Two patients with extensively vacuolated meningiomas are described. The first, a 51-year-old female who had had several convulsive seizures within a 3-month period, was found on a plain computed tomography (CT) to have a diffuse, hypodense lesion in the frontoparietotemporal region. Contrast enhancement was slight. Neuroradiological examination suggested an extra-axial mass lesion. Histopathological examination of the surgical specimen showed extensive vacuolation and meningothelial cell nests, and a diagnosis of meningioma was established. No lipids were demonstrated in the vacuolated component. Electron microscopy of a formalin-fixed specimen showed interdigitations of cytoplasmic processes and desmosomes. Cytoplasmic processes also delimitated intercellular spaces of variable size. The second patient, a 68-year-old female, had had several right facial spasms within 6 months before admission. Plain CT revealed a hypodense lesion in the left frontotemporal region. Enhanced CT showed a well defined mass lesion. Light microscopy of the tumor specimen showed an area of mixed vacuolated and angiomatous components. It is important to note that the CT appearance of such hypodense meningiomas may mimic that of intra-axial tumors, such as filial tumors. The low density is considered to be due to extensive, diffuse vacuolation. Electron microscopic findings suggest that one of the causes of vacuolation in vacuolated meningioma is recapitulation of the subarachnoid structure.

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Neoplastic Aneurysms due to Cerebral Metastasis of Choriocarcinoma

Report of Two Cases

Manabu HISANAGA, Shozo KAWAI, Mototsugu MAEKAWA, Yutaka HATTORI, Kiyos ...

1988 Volume 28 Issue 4 Pages 398-403
Published: 1988
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.28.398

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Two cases of neoplastic aneurysm due to cerebral metastasis of choriocarcinoma are described. One patient, a 28-year-old female, complained of sudden onset of headache, nausea, and vomiting. On admission there were no neurological deficits. A lumbar puncture yielded xanthochromic cerebrospinal fluid. Right carotid angiography revealed posterior circulation through the primitive trigeminal artery and a small aneurysmal shadow in a peripheral branch of the left posterior cerebral artery. Left occipital craniotomy was performed. Subdural and intracerebral hematomas were evacuated. The second patient was a 32-year-old Thai housewife who complained of headache, nausea, and vomiting 5 days after a right upper lobectomy for a lung tumor. Computed tomography showed a small high-density area in the right occipital lobe. There was no neurological deficit or nuchal stiffness. Right carotid angiography revealed three small aneurysms in the peripheral branches of the middle cerebral artery. Partial right occipital lobectomy and evacuation of a hematoma were performed. Postoperative angiography performed after cancer chemotherapy had been administered three times showed disappearance of the aneurysmal shadows. The patient died of rebleeding 5 months after the onset of neurological symptoms. In both cases the diagnosis of choriocarcinoma was histologically established.
To data, only 11 cases of neoplastic aneurysm due to choriocarcinoma have been reported, and none involved the posterior circulation nor was associated with the primitive trigeminal artery. Disappearance of neoplastic aneurysms on angiograms obtained after chemotherapy is also rare.

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Posterior Inferior Cerebellar Artery Dissecting Aneurysm presenting with Wallenberg's Syndrome

Case Report

Hirokazu KOMIYA, Naokatsu SAEKI, Yasuo IWADATE, Kenrou SUNAMI, Akira Y ...

1988 Volume 28 Issue 4 Pages 404-408
Published: 1988
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.28.404

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A 37-year-old nonhypertensive male suddenly experienced mild left suboccipital pain while driving. In addition to neck pain persisting for 5 days, he began to experience vertigo and cold sensation in the right hand. On admission the patient was alert and cooperative. He had no neck stiffness. Clinical examination revealed typical Wallenberg's syndrome. Routine laboratory investigations were all normal. A computed tomographic scan revealed no abnormalities. Left vertebral angiography showed a fusiform shadow at the proximal posterior inferior cerebellar artery (PICA), but neither double lumen nor pooling of the contrast medium in the venous phase was observed. Left retromastoid suboccipital craniectomy disclosed no evidence of recent subarachnoid hemorrhage. The proximal PICA was enlarged for a distance of 1 cm, beginning 5 mm distal to its vertebral origin. Both the enlarged portion and a segment just distal to it were purplish-red. It was diagnosed as a dissecting aneurysm of the PICA with distal extension. Proximal ligation of the PICA was successful, and the patient was discharged with no deficits.
It must be emphasized that vertebrobasilar aneurysms should be carefully ruled out in patients with Wallenberg's syndrome, particularly those who are fairly young and not predisposed to hypertension or arteriosclerosis, and in whom the initial symptom is unusual headache.

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Inverted Papilloma of the Nose and Paranasal Sinuses with Transdural Intracerebral Extension accompanied by Brain Abscess

Case Report

Koichi UCHIDA, Tohru MINE, Nobuo TAKENAKA, Hiroshi INOUE, Hideo NAMEKI ...

1988 Volume 28 Issue 4 Pages 409-414
Published: 1988
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.28.409

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A 64-year-old male who had repeatedly undergone polypectomy for nasal polyps over a 20-year period was hospitalized with a “heavy feeling” in the head and disturbance of memory. Physical examination revealed the right nasal fossa to be almost completely blocked by a granular polyp. Neurological examination disclosed slightly impaired mental function, slight right exophthalmos, and bilateral papilledema. Skull X-rays revealed homogeneous clouding of the right nasal cavity and paranasal sinuses and an expansile lesion, resembling a mucocele, in the right frontal sinus. Computed tomography (CT) disclosed a soft-tissue mass in the right nasal cavity, paranasal sinuses, and orbit, with expansion of the right frontal sinus and destruction of the nasal septum, medial wall of the orbit, and roof of the frontal sinus. A patchy intracerebral mass with ring-like enhancement lay close to the expanded frontal sinus. Histological examination of the mass in the nose and paranasal sinuses showed typical inverted papilloma with a small malignant focus, and the diagnosis was squamous cell carcinoma. The intracerebral mass, which was also an inverted papilloma, was accompanied by a brain abscess and was not malignant. Intracranial extension is apparently a rare complication of inverted papilloma; only six such cases have been reported in the world literature. This appears to be the first reported case in which an inverted papilloma destroyed the dura mater and invaded the brain.

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