Central pain due to stroke, spinal cord injury and surgical or traumatic brain injury is frequently refractory, and therefore, electrical stimulation therapy including stimulation of the spinal cord, thalamus and cerebral cortex is indicated. In this report, we discuss a strategy for dealing with central pain.
Spinal cord stimulation has been thought to be ineffective as a treatment for central pain. However, it is a less invasive therapy and is sometimes effective even on the post-stroke pain of extremities. On the other hand, cerebral cortex stimulation has recently been more popular as a treatment for post-stroke pain, and successful cases of treatment have also been documented following spinal cord injury. At the present time, it is difficult to conclude whether cerebral cortex or thalamic stimulation is more effective in the treatment of spinal cord pain.
We discuss our strategy for central pain. Medication and observation for at least one year is needed before surgical therapy is considered. If medication is not effective, spinal cord stimulation should be considered. Next, cerebral cortex stimulation is recommended, and depending on the patient's condition, thalamic stimulation may also be indicated.

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Stroke remains the second or third cause of death and a major cause of adult disability in Japan. Management of stroke patients should be done in the Stroke Center or the Stroke Care Unit with their highly specialized diagnostic and treatment teams. A Stroke Care Unit (SCU) was opened in the Tokushima University Hospital in November 1999.
The diagnostic category of 295 stroke patients registered in our SCU until September 2002 was cerebral infarction in 175 patients (59.3%), intracerebral hemorrhage in 55 patients (18.4%), subarachnoid hemorrhage in 36 patients and others in 29 patients (9.8%). Stroke MRI combined with diffusion-weighted MRI (DWI), perfusion-weighted MRI (PWI), T2-weighted MRI and MR angiography were useful in detecting early cerebral ischemic lesions and evaluating indication of thrombolysis.
Thirty-seven (21.1%) of 175 patients with ischemic stroke underwent surgical or endovascular reconstruction. However, the outcome of the patients with embolic occlusion of the internal carotid arteries or proximal middle cerebral arteries was still unsatisfactory.
We discuss the significance and problems in the SCU of the National University Hospital.

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Current medical reforms require functional specialization of hospitals and clinics and designation of hospitals for acute- or chronic-term care. These reforms are expected to produce the merit of patients returning to the primary-care physician who got used to circulate by short hospitalization period.
Many hospitals focus on acute-term medical treatment. But it will likely be difficult for the present number of sickbeds to meet the needs of acute-term care as it is. So, changing into a chronic-term hospital is a decision that requires courage for the manager and administrator of many hospitals. First of all, a decrease in the number of days of hospitalization will bring about a fall in the rate of operation of the hospital if the number of new patients does not increase. To shorten the hospitalization days as whole, it is required not only to decrease the hospitalization days for every disease, but to reduce long term hospitalizations. Second, scramble of acute term patients becomes severe. It is becoming a still more difficult time that acute term hospitals live together in the same demographic division of medical services.

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To clarify the effects of systemic complications on the outcome of patients with spontaneous intracerebral hemorrhage (ICH), we studied 201 patients retrospectively to collect information on the severity of ICH and the clinical courses, as well as on systemic complications such as pneumonia, cardiac episodes, gastrointestinal complication, liver damage, renal impairment and urinary tract infection. We then statistically analyzed those factors in relation to the patients' backgrounds and outcomes.
Pneumonia was the most frequent cause of death in patients with moderate ICH severity, and it was significantly correlated with patients' age, Glasgow Coma Scale (GCS) on admission, the maximum diameter of ICH, and the National Institute for Health Stroke Scale (NIHSS) 1 month after ICH. Lethal pneumonia tended to occur within the acute phase of ICH, and death by pneumonia was usually observed in the subacute or early chronic phase, compared with death by ICH (acute phase) or by other causes (late in the chronic phase). In addition, patients who had suffered from pneumonia were significantly more likely to have other medical complications than were patients without pneumonia.
A great deal of attention should be paid to the management of pneumonia, especially in high-risk patients or patients manifesting clinical signs of pneumonia in the acute phase of ICH.

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Based on the results of 11 cases of symptomatic brainstem cavernous angiomas (CA), we studied treatment strategy, surgical indication, selection of surgical approaches and other clinical problems. CAs were the pons in 8, the midbrain in 2 and the medulla in 1 patient. Five of the 11 cases were treated by direct surgery and the others had conservative treatment. Surgical cases commonly had progressive or persistent neurological deficits caused by repeated episodes of hemorrhage. The selected surgical approaches were trans 4th ventricular in 3 (via suprafacial triangle in 2, infrafacial triangle in 1), occipital transtentorial in 1 and retrosigmoid in 1 patient. Two recent patients had brainstem mapping or monitoring during operation. Total removal was done in 3, and partial removal with coagulation of CA was done in 2 cases.
Transient PPRF and facial dysfunctions developed in all cases with the trans 4th ventricular approach. But permanent facial paralysis remained in 1 patient without intraoperative monitoring. Long-term follow-up (mean of 54.6 months) showed no recurrent hemorrhage and mean KPS score was 84.
These results indicate that direct surgery to brainstem CA is safely and successfully performed by appropriate selection of patients and surgical approaches under careful monitoring.

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We examined the role of the STA-MCA bypass for chronic ocular ischemic syndrome due to the internal carotid artery (ICA) occlusive diseases.
We examined 44 patients having chronic ocular ischemic syndrome due to the ICA occlusive diseases treated with STA-MCA bypass. Their visual symptoms were decline of visual acuity in 31 cases, frequent amaurosis fugax in 6 cases and both in 7 cases. In each patient, the ophthalmic artery flow was examined with color Doppler flow imaging (CDF) providing the flow direction, waveform and peak systolic flow velocity (PFV) before, at 1 month, and 3 months after surgery. Ophthalmologic examinations such as the visual acuity, retinal artery pressure and optic fundus were also examined.
CDF findings: 1) Preoperatively, 39 patients showed reversed ophthalmic artery flow (average PFV: -0.32±0.16 m/sec). The other 5 patients showed antegrade ophthalmic artery flow (average PFV: 0.09±0.03 m/sec). 2) At 1 month after bypass, 17 patients showed the antegrade ophthalmic artery flow. Two of them showed the normal ophthalmic artery flow. Average PFV in the patients with preoperatively reversed ophthalmic artery flow significantly rose to -0.09±0.22 m/sec (p<0.05). 3) At 3 months after surgery, 21 patients showed the antegrade flow, and 5 of them showed the normal ophthalmic artery flow. The average PFV in the patients with preoperatively reversed ophthalmic artery flow significantly changed to 0.08±0.05 m/sec (p<0.05). There was no significant change of CDF finding in patients with preoperative antegrade ophthalmic artery flow at 1 month and 3 months after surgery.
Visual symptoms: During the follow-up period (mean 4.5 years), no patients complained of recurrent visual symptoms. At the final stage, visual acuity improved in 18 patients (47%) and did not worsen in any of the remaining 26 patients. Ophthalmologic examinations also improved during the follow-up period.
STA-MCA bypass played a useful and important role for the improvement or prevention of progress of the ocular ischemic syndrome due to the occlusive ICA diseases, especially for patients showing reversed ophthalmic artery flow.

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We report 8 patients with growing thrombosed aneurysms in the posterior fossa, all of which seriously compressed the brain stem or medulla oblongata. Angiographically, 7 of 8 cases were categorized as so-called fusiform or dolichoectatic aneurysms and 1 case was a saccular aneurysm at the basilar artery fenestration. The unilateral vertebral artery was involved in 4 cases, the basilar artery in 2 cases, and the vertebro-basilar artery in 2 cases. The 7 males and 1 female ranged in age from 38 to 64 years (mean: 48.8 years). Hypertension and hypercholesterolemia were noted in all the patients.
The 3 large aneurysms at the vertebral artery were excised after occipital artery (OA)—posterior inferior cerebellar artery (PICA) anastomosis in 2 cases and endarterectomy of the contralateral vertebral artery stenosis in 1 case. The bypass functioned well and patients recovered well.
The 4 giant aneurysms of the vertebral and/or basilar artery were treated by a Hunterian ligation and high-flow bypass using the radial artery graft between the extracranial vertebral artery and the posterior cerebral artery (PCA). An inverted flow direction and termination of the aneurysmal sac led to the stagnation of the blood stream in the aneurysmal dome. However thromboembolism from intra-aneurysmal clot induced serious brain stem infarction in 3 cases, and aneurysmal growth after surgery was noted in all cases.
To prevent intra-aneurysmal clotting in the acute phase, strong heparinization is essential and a second step to excise the growing aneurysm in the chronic phase is also required.

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Because ventrally directing IC aneurysm is sometimes difficult to treat by the standard pterional approach, we attempted to modify our distal transsylvian approach. We describe this modified distal transsylvian approach (anterior temporal approach) in this paper.
The surgical method comprises the following steps; 1. Superficial sylvian veins are displaced to the frontal side of the fissure without sacrificing those veins. An anastomotic trunk of the deep middle cerebral vein is dissected from the medial temporal lobe. 2. A posterior division of M2 segment, M1 segment and anterior temporal artery are dissected from the medial temporal lobe. 3. Arachnoid trabecula between the uncus and the anterior choroidal artery is incised. This allows posterolateral retraction of the temporal pole without significant retraction.
Although the anterior temporal approach is employed for the surgical treatment of distal BA aneurysm, it is also available for the IC ventral aneurysm.

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We evaluated the neuropsychological function in 46 patients with unruptured cerebral aneurysms who showed a good outcome postoperatively.
Seventeen patients (37%) showed deterioration of test results 1 month after surgery compared with preoperative evaluation. Although no patients showed deterioration on mini-mental state examination, Kohs's block-design test results had deteriorated in 5% of patients, “Kana-hiroi” test in 17%, and paired associate learning test in 28%. Age, presence of systemic diseases and aneurysm location had detrimental effects on these psychological examinations. Three patients (7%) still showed deterioration of test results 6 months after surgery.
These results suggest that the neuropsychological outcome after surgery for unruptured cerebral aneurysms was not satisfactory even in patients with good outcome, and that neuropsychological examination is necessary to evaluate surgical results considering the quality of the patient's life.

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A 71-year-old woman was admitted to our hospital with depression that had begun 1 month prior to admisson. Eight years before, she had received radiation therapy (total 60 Gy) for laryngeal cancer. Neurological examination on the admission was normal, but self-rating depression scale (SDS) score showed severe depression. Magnetic resonance imagings demonstrated a small old cerebral infarction in the right cingulate gyrus and multiple lacunar infarctions in subcortical regions. Angiography revealed complete occlusion of the right common carotid artery (CCA) and severe stenotic lesions of the left CCA. Positron emission tomography (PET) showed a decrease of cerebral blood flow (CBF) in the bilateral cerebral hemispheres.
The patient underwent a reconstructive surgery for the right CCA. There was no adhesion of skin and subcutaneous tissue, and after arteriotomy the atheromatous plaque was easily removed. After the operation, she was relieved of depression and her SDS score remarkably improved. Postoperative angiography showed the recanalization of the right CCA, and PET revealed an increase of CBF of bilateral cerebral hemispheres.
Vascular depression (VD) is a mood disorder caused by cerebrovascular disease, especially cerebral infarctions. In this case, the depression improved remarkably after the carotid endarterectomy, which resulted in an increase of CBF.
This case suggests that there may be CBF-dependent and surgically treatable VD in patients with major depressive disorder.

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We report a rare case of a large thrombosed aneurysm at the peripheral artery of the middle cerebral artery presenting subarachnoidal hemorrhage after the Ramsay Hunt syndrome. A 64-year-old male who had suffered from Ramsay Hunt syndrome suddenly presented consciousness disturbance and the left hemiparesis on April 12, 2001. CT showed a subarachnoid hemorrhage mainly in the right sylvian fissure. MRI showed a low intensity mass on T2-WI. His right carotid angiogram revealed a dilatation of the parietal artery with a retention of the contrast material.
Surgery was performed on April 13. Aneurysm with the large thrombus had neck at the dilatic lesion in the parietal artery. Neck clipping and coating at the dilated parietal artery was performed.
The postoperative course was good, but he developed left hemiparesis again on April 22. On April 23, CT showed infarction in the right middle cerebral artery territory. Right carotid angiogram revealed an occlusion of the parietal artery and segmental stenosis of the angular artery.

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