The authors investigated the mechanism of the re-buildup phenomenon on electroencephalogram in 14 patients of moyamoya disease with superficial temporal artery-middle cerebral artery anastomosis. Visualization of the lateral view of the common carotid angiography was performed with intra-arterial digital subtraction angiography (IA-DSA), using a 4/sec × 3 sec + 2/sec × 5 sec + 1/sec × 5 sec film sequence. The catheter tip was inserted into C5/6 level and 250 mgI/ml of iopamidol was used as the contrast agent; 6 ml in total was injected over 1.5 seconds. Circulation times of the common carotid artery (C₃ portion)-ascending parietal vein (ΔTTP_S) and common carotid artery-internal cerebral vein (ΔTTP_D) were measured before hyperventilation (HV), immediately after HV, and 3 minutes after HV during pre and postoperative periods. ΔTTP_D in the preoperative period was prolonged by HV and was normalized at 3 minutes after HV but ΔTTP_S were prolonged immediately after and 3 minutes after HV. In the postoperative period, however, these values did not change significantly immediately after and 3 minutes after HV. These findings indicate that delayed cerebral blood flow response to HV is a pathogenetic factor of the re-buildup phenomenon in moyamoya disease.

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Eight patients with vertebral artery (VA) stenosis at its origin were surgically treated by a new reconstructive technique. Two patients suffered vertebrobasilar transient ischemic attacks, and five had brainstem and/or cerebellar infarction. All patients had multiple stenotic lesions, including bilateral VA stenoses in one and unilateral VA stenosis plus contralateral VA occlusion in seven. They underwent a subclavian artery to VA bypass using a saphenous short vein graft with external shunting. Postoperatively, no patients had aggravated neurological symptoms, and angiography showed all bypasses to be patent. One had an episode of transient loss of consciousness 8 months postoperatively, but the others showed no episodes of ischemia during an average follow-up period of 2 years and 10 months. The results indicate that this procedure is safer and more useful than other surgical procedures.

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The authors experienced 1903 cases of ruptured aneurysm between 1961 and 1986. Most cases were treated by clipping or ligating the aneurysmal neck. However, these procedures were impossible in 52 cases (2.7%), for which wrapping alone (21 cases), aneurysmal body clipping and wrapping (11 cases), or body ligation and wrapping (20 cases) was performed. We studied the long-term results in 44 of these 52 cases. Rerupture occurred in only two cases with incomplete wrapping. We concluded that complete wrapping, and wrapping of residual portions following aneurysmal body clipping or body ligation produce favorable results.

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We report on three cases of remote cerebellar hemorrhage after supratentorial craniotomy, which had much in common in their computed tomographic, operative, and clinical findings. We speculate that, when the patient is in the supine position, displacement of the cerebellum causes stretching of the superior vermian veins and their tributaries, resulting in tearing of these vessels. Postoperative cerebrospinal fluid overdrainage or massive air reflux into the cranial cavity through the drainage tube may accelerate this process. Meticulous management of the drainage system is necessary to prevent this postoperative complication.

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A 53-year-old male suffered a transient right hemiparesis and left monocular blindness. Angiography revealed 80% stenosis of the cavernous carotid artery. Microsurgical thromboendarterectomy was performed by a direct approach through Parkinson's triangle. During surgery, the carotid circulation was transiently trapped between the cervical and the supraclinoid segment and the trapped arterial lumen was irrigated with heparinized saline. Soft elastic lesion was easily removed. Cavernous carotid thromboendarterectomy through a direct approach is considered as a suitable operation for the solitary and localized stenotic lesions of the cavernous carotid artery, although this operation has not yet been reported to date.

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An intra-abdominal cyst is a rare complication of ventriculoperitoneal (VP) shunt. A 19-year-old male was admitted complaining of abdominal pain and distension, dysuria, constipation, headache, and fever. He had undergone a VP shunt for obstructive hydrocephalus caused by a cerebellar astrocytoma 16 years earlier, and had received shunt revision twice, 5 years and 3 months earlier, respectively. Examination on admission revealed neck stiffness, early papilledema, a mass in the lower abdomen, and abdominal muscular guarding with rebound tenderness. Laboratory studies showed leukocytosis of the peripheral blood and pleocytosis of the cerebrospinal fluid (CSF). Abdominal ultrasonograms and computed tomographic scans demonstrated a cystic lesion. Under the diagnosis of meningitis and local peritonitis with an intra-abdominal cyst, we sistemically administered antibiotics and externalized the shunt. However, since the cyst fluid could not be aspirated through the abdominal catheter, it was exchanged with a flexible catheter under fluoroscopic control, according to Seldinger's method. A total of 400 ml of cyst fluid was drained. Staphylococcus epidermidis was detected in both the cyst fluid and the CSF. After meningitis subsided, repositioning of the abdominal catheter into the other side of the abdomen was performed but resulted in shunt malfunction and meningitis due to the same organisms. After meningitis again subsided, the VP shunt was converted to a ventriculoatrial shunt. The clinical course was uneventful thereafter.

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The authors report an unusual case of arteriovenous communication between extracranial and intracranial vessels, accompanied by incidentally detected bilateral arachnoid cysts of the middle cranial fossa. A 52-year-old male was admitted with a sudden onset of headache, vomiting, and conjunctival hyperemia of the right eye followed by progressive chemosis and proptosis. He had undergone a craniotomy for hypertensive right putaminal hemorrhage 4 months previously. Angiography showed the main feeding artery to be the superficial temporal artery and the draining veins to be the superficial Sylvian veins and the basal vein of Rosenthal. Partial obstruction of the right cavernous sinus was also shown. At surgery, granulation tissue continued to the dura mater through the skull aperture of previous craniotomy and adhered to the underlying damaged cerebrum. The extremely unusual nature of the communication, the operative findings, and the atypical fistulous figures suggested that communication had occurred postoperatively via newly generated vessels in granulation tissue.

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Intracranial fibrous xanthoma is extremely rare; only 11 cases have been reported so far. The authors report a case of multicentric intracranial fibrous xanthoma. Precontrast computed tomographic (CT) scans revealed a left frontal subdural mass, which had previously been diagnosed as a chronic subdural hematoma at another hospital. However, operation disclosed no hematoma but a granulomatous tumor. The biopsied specimen was histologically diagnosed as fibrous xanthoma. Postoperative postcontrast CT scans showed intense homogeneous enhancement at the clival and the left frontal regions, both of which appeared as iso to low-intensity areas on T₁-weighted magnetic resonance (MR) images and as low-intensity areas on T₂-weighted MR images. She gradually recovered by conservative treatment but suddenly died of cerebral infarction. Autopsy revealed fibrous xanthomas in the left frontal and the clival regions. This is the first report of the use of MR imaging for intracranial fibrous xanthoma, and its features differ from those of common intracranial parenchymal tumors. MR imaging can be helpful in the diagnosis of this tumor.

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The authors report a rare case of non-functioning pituitary carcinoma with spinal cord metastasis. A 37-year-old female presented with a 2-month history of right retro-orbital ache and vomiting. She had a pituitary adenoma removed 3 years prior to admission. Neuroradiologically, a mass lesion was demonstrated in the right middle cranial fossa. The tumor was removed through craniotomy and was histologically diagnosed as pituitary carcinoma. One week after the operation, tetraplegia developed and CT scans demonstrated a spinal canal lesion. Although the tumor was removed through C3-C7 laminectomies, she gradually deteriorated and died. At autopsy, a tumor was disclosed in the right temporal lobe and basal ganglia. Moreover, the tumor invaded into the middle cranial fossa and the parasellar region.

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The authors report a case of repeated brain metastases from hepatocellular carcinoma (HCC) in a 70-year-old male, who had underwent liver segmentectomy for HCC 5 years earlier. He developed intracerebral hemorrhage in the right parietal region, which was considered to be intratumoral because the metastatic tumor was detected in the same region. Total removal of the tumor and hepatic artery embolization followed by ethanol injection for recurrent HCC were performed. One month later, a metastatic tumor was discovered in the upper vermis and was totally removed. Both metastatic brain tumors were histologically verified as Edmondson grade 2 HCC. Four months later, multiple metastases to the left frontal region and the upper vermis occurred, and he died of pneumonia. Brain metastasis from HCC is rare; nine such cases have been reported in the literature, of which eight cases developed intracranial hemorrhage as in the present case.

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