Cell density regulates crypticity of GM3 ganglioside on human glioma cells

Human glioma cell line KG-1C contains GM3 ganglioside as its sole glycolipid. The degree of M2590 antibody binding to GM3 was found to be regulated by the cell density; the percentage of positive cells in FACS analysis decreased from approximately 20% to close to none as the cells increased their density from sparse to confluent. The contents of GM3 with different cell densities were consistent, being more than 0.4 micromol/g of the cellular weight, which was high enough to be recognized by the antibody. Trypsin treatment of the cells did not increase antibody reactivity. The extracted GM3 retained its antigenicity, being intensely stained with M2590 on a TLC plate; there was no change in chromatographic mobility either, indicating no modification of its chemical structure. The fluorescent microscope disclosed scattered dot-like staining of GM3, particularly at the periphery of the cells. We were able to expose cryptic GM3 fully within 12 h by dispersion of the cells to a sparse density. Surface labeling of GM3 with the use of limited sodium periodate oxidation of sialylated residue equally labeled GM3 either from the confluent cells or the sparse cells. Disassembly of actin filaments with cytochalasin B (10 microM) partially exposed cryptic GM3 of confluent cells, indicating reversibility of the crypticity. All together, the results indicate that cryptic GM3 actually exists on the cell surface, hidden from the surface not by other molecules but by other mechanisms associated with the cellular architecture. We are beginning to explore the possibility of selective localization of GM3 in small caves or folds of the cell membrane produced upon cell-to-cell contact.

Lymphoplasmacyte-rich meningioma with clinical resemblance to inflammatory pseudotumor. Report of two cases

Two cases of lymphoplasmacyte-rich meningioma manifesting clinical and radiological characteristics unusual for a meningioma are reported. The patient in Case 1 was a 22-year-old man with a 9-year history of bilateral visual disturbances and recent dyspnea. An en plaque skull base mass, which was partially resected, was found at surgery to extend down from the planum sphenoidale into the spinal canal to C-5. Seven years later most of the residual mass in the spinal canal had disappeared, although a localized round tumor recurred at C2-3. The patient in Case 2 was a 24-year-old woman with an original diagnosis of clival meningioma, which recurred as multiple skull base lesions that spontaneously regressed in 10 months. These two cases and others reported in the literature indicate that lymphoplasmacyte-rich meningiomas may manifest peculiar biological behavior more typical of intracranial granulomas than of meningiomas.

[Two cases of delayed posttraumatic vasospasm followed by brain SPECT]

This is a report of two cases of delayed posttraumatic vasospasm. In case 1, a 68-year-old male was injured by falling. He did not show any neurological deficits on admission. CT scan revealed a diffuse subarachnoid hemorrhage (SAH) without brain contusion. Aneurysm was not disclosed by angiography. On the 7th day after admission, he presented disorientation. Reviewed angiography revealed diffuse delayed vasospasm. 123I-IMP brain SPECT showed an extensive low perfusion area in the bilateral parietal portion. In case 2, a 71-year-old female experienced immediate development of a deep comatose state after head injury. CT scan on admission disclosed a massive acute left subdural hematoma and the severe compression of the left cerebral hemisphere by the hematoma. But traumatic SAH was not diffuse and was restricted to the left basal cistern. After emergency operation, her consciousness level improved and the mass effect of the subdural hematoma was diminished. On the 7th day after the operation, her neurological condition worsened. CT scan showed some infarction lesions in the left cerebral hemisphere and mild left cerebral swelling. Angiography on the same day revealed vasospasm in M2-M3 portion of left middle cerebral artery. HM-PAO brain SPECT disclosed low perfusion in the left parietal region, but a state of high perfusion in the other region. In case 1, vasospasm might have been derived from diffuse clots of traumatic SAH caused by the same process as postruptured aneurysmal vasospasm. In case 2, the region of vasospasm was not associated with traumatic SAH. It corresponded to the site of the brain contusion. It was suggested that the cause of vasospasm might have been the direct mechanical injury to the arterial wall and chemical substances deriving from the contused brain tissues. We conclude that SPECT or transcranial Doppler monitoring should be used for the early detection of posttraumatic vasospasm.

Supratentorial glioma manifesting as acute onset of pure motor hemiparesis--case report

A 68-year-old male presented with an anaplastic astrocytoma deep in the sensorimotor cortex manifesting as acute pure motor hemiparesis suggestive of a vascular mechanism rather than tumor mass effect. Perfusion-weighted magnetic resonance (MR) imaging showed a significant decrease of blood flow in the sensorimotor area, where fluid-attenuated inversion recovery imaging demonstrated a prominently edematous area. Angiography also suggested ischemia with poor visualization of the precentral and central arteries. Diffusion-weighted MR imaging failed to identify the edema as cytotoxic or vasogenic due to technical problems. Brain tumors may manifest through impairment of peritumoral blood supply, which can be clarified by recent MR methods.

[Hippocampal hemosiderin deposit due to large pituitary adenoma presenting temporal lobe epilepsy--a case report]

There have been reports of epilepsy associated with pituitary adenoma, but the epileptogenic zone and its histopathology have never been sufficiently described. We report a case of pituitary adenoma complicated by temporal lobe epilepsy, in which the epileptogenic focus was identified, resected, and examined histopathologically. The patient was a 38-year-old man on bromocriptine therapy for a huge pituitary adenoma (prolactin-producing) since 1985. He also had a history of temporal lobe epilepsy since 1989. CT images in 1985 revealed the tumor extending to the supra- and left para-sellar region. MR images in 1995 showed a significant decrease in the size of the tumor and a signal void area that was interpreted as a hemosiderin deposit in the left mesial temporal lobe. Ictal EEG demonstrated that seizure discharges were elicited at the left sphenoidal electrode and propagated to the both temporal lobes. Interictal SPECT revealed a local area of hypoperfusion in the left fronto-parietal lobe. An epileptogenic focus in the left mesial temporal lobe was diagnosed on the basis of the above examinations. The patient was treated by left anterior temporal lobectomy with partial hippocampectomy. Hemosiderin deposition in the hippocampus was suspected during surgery. Histopathological examination showed pyramidal cell loss and gliosis in the left hippocampus and confirmed the presence of hemosiderin in the CA1 region. The hemosiderin deposition in the hippocampus was inferred to have resulted from intratumoral hemorrhage due to bromocriptine therapy, and it may have caused the temporal lobe epilepsy in this patient. The outcome of surgery was freedom from seizures for eight months. Intra-tumoral hemorrhage in mesial temporal structures must be borne in mind as one of the epileptogenic mechanisms in pituitary adenoma, especially in cases in which hemosiderin is detected on MR images.

[Factors influencing the long-term function of the facial nerve following removal of acoustic neurinomas]

Thirty-five cases with removal of acoustic neurinomas were reviewed to demonstrate the factors which influenced the postoperative long term function of the facial nerve. All cases were operated on via a suboccipital route. The group consisted of 7 cases with the tumor confined to the internal auditory meatus, 4 cases with a neurinoma of 20 mm or less in diameter, 13 cases with a neurinoma of 30 mm or less, and 11 cases with a neurinoma over 30 mm. The consistency of the tumors was solid in 27 cases, and cystic in 8 cases. Dislocation of the facial nerve was observed during the operation except in 7 intrameatal cases. The dislocation is summarized as follows: dislocated in the cranial direction in 2 cases, ventrocranial in 7, ventral in 5, ventrocaudal in 10, dorsocaudal in one, and caudal in 3 cases. No case showed dislocation of the facial nerve in the dorsocranial or dorsal direction. Careful observation of the facial nerve at the entrance of the internal auditory meatus showed a severe kinking in 2 cases, moderate kinking in 2, but no kinking at all in the remaining 31 cases. The facial nerve was preserved anatomically in all cases. Long term function of the facial nerve can be summarized as excellent in 18 cases, good in 8 cases, and poor in 9 cases. Three cases showed an almost complete paresis of the facial nerve immediately after the operation and recovery was never observed. Neurinoma facial score was defined in 28 cases, except intrameatal cases, according to the degree of preoperative facial nerve function, tumor size, presence of the cystic component within the tumor, direction of the facial nerve dislocation, and the presence of kinking of the facial nerve. The correlation between the long-term facial nerve function and the neurinoma facial score was statistically examined and was found to be significant (Sperman's correlation coefficient by ranks; rs = 0.38596 > 0.375; P = 0.05). In conclusion, neurinoma cases that show the least facial nerve function are: cases in which facial function had deteriorated, cases in which the tumor was large or when the tumor had no cyst, when dislocation of the facial nerve was in the cranial direction, and in cases where there was kinking of the facial nerve at the internal auditory meatus. In such cases, the removal should be carried out intracapsularly so as to preserve facial nerve bundle which may spread and become flattened like a tumor capsule. This might minimize the postoperative deterioration of the facial nerve function.

[Characteristics of visual impairment complicated with planum sphenoidale and tuberculum sellae meningiomas and their surgical results]

It is well known that it is difficult to remove the planum sphenoidale and tuberculum sellae meningioma without damaging the optic nerves. The visual outcome after this operation has been unacceptable in such tumors, especially in large ones. This review propounds a strategy to secure visual acuity through operation. A total of eight cases are summarized. In five midline symmetrical meningiomas, the tumors compressed the nerves at the portion of the optic chiasma, causing a typical bitemporal hemianopsia. Four large tumors were resected by the frontobasal interhemispheric approach to minimize the intraoperative damage to the optic chiasma, and a small one was removed by the pterional approach. Visual deficits were recovered immediately after the operation in all cases without any surgical complications. Three meningiomas were attached to the lateral part of the planum sphenoidale or tuberculum sella. Although the sizes were relatively small in all cases, they caused ipsilateral severe visual loss by direct compression to optic nerves. MRI and three-dimensional CT angiography showed the tumor extension into the optic canal. The ipsilateral pterional approach was selected in these cases. To avoid additional nerve damage, we tried to reduce the tension of nerves which were compressed by the tumors. We removed the anterior clinoid process and opened the optic canal before surgical manipulation of the tumor. In two cases, tumors severely compressed the optic nerves from the medial side, and nerves were stretched laterally. Great care was required to separate the optic nerves from tumors in those two cases. In contrast, the resection seemed to be very easy in one of the cases where the optic nerve was displaced infero-medially. Visual symptoms were improved in all cases, although one case became worse temporarily. Although planum sphenoidale and tuberculum sellae meningiomas are still troublesome, appropriate preoperative management would allow us to expect an excellent visual outcome. Especially, selection of the surgical approach should be based on the anatomical analysis of the nerve displacement.

[Evaluation of carotid artery stenosis with three-dimensional CT angiography and surgical revascularization]

The accuracy of three-dimensional CT angiography (3D-CTA) for delineating atherosclerotic carotid stenosis was examined in comparison with digital subtraction angiography (DSA) in symptomatic patients. In cases undergoing carotid endarterectomy (CEA), the clinical usefulness of 3D-CTA for surgical planning was also evaluated in the light of intraoperative findings. From July 1992 to June 1995, 52 patients suffering from internal carotid ischemia and/or presenting carotid bruit were evaluated to detect carotid bifurcation stenosis by 3D-CTA. Shaded surface reconstruction (SSR) for three-dimensional display and maximum intensity projection (MIP) were employed in multiple projection to evaluate sites of stenosis. DSA was performed in 18 out of 31 patients having atherosclerotic carotid stenosis shown by 3D-CTA. MIP reconstructions accurately delineated sites of stenosis close to DSA and allowed precise depiction of ulcerated plaque and intramural calcification. The percentage of carotid stenosis was determined by comparing the narrowest point to the internal carotid artery (ICA) beyond the bulb on both 3D-CTA and DSA. Assessment of carotid stenosis was highly correlated between 3D-CTA and DSA (r = 0.987, p < 0.0001). In this series, 9 carotid arteries in 8 patients underwent CEA for severe stenosis. 3 patients with ICA occlusion and 1 patient with elongated severe stenosis underwent STA-MCA anastomosis. Using MIP reconstructions and two-dimensional original images it was found that ICA occlusion was apparently distinguished from high grade ICA stenosis. SSR provided valuable informations during CEA for atherosclerotic plaque regarding anatomical relationship with the internal jugular vein and bony structures. This advanced means of 3D-CTA can be adequate as a screening method to detect carotid stenosis in symptomatic patients and useful for surgical planning of CEA and post-operative follow-up examination.

[Seizures as a late complication of bromocriptine therapy in patients with prolactin-producing macroadenomas: correlation between lateral extension of the adenoma and seizure onset]

Seizures have been reported as a late complication of medically treated prolactin-producing macroadenomas with lateral extension. Nine prolactin-producing macroadenomas with lateral extension to the cavernous sinus were treated with bromocriptine alone. In all cases, rapid decrease of serum prolactin level was recognized and in eight cases, evidence of tumor shrinkage on CT or MRI was demonstrated. During medical treatment, symptomatic seizures occurred in three cases. MRI showed small residual tumors on the medial surface of the temporal lobe in all these patients. Additionally, a hypointense signal on both T1- and T2-weighted images was recognized around the residual tumor. It was consistent with hemosiderin, a result of intratumoral hemorrhage caused by bromocriptine. On the contrary, the remaining six patients without seizures during treatment did not show abnormal hypointense signals on the medial surface of the temporal lobe. Seizures occur with a high incidence as a late complication of medical treatment of prolactin-producing macroadenomas with intradural supracavernous extension. The patients with seizure show hemosiderin deposit, which may be the trigger of the seizure, within the medial surface of the temporal lobe after bromocriptine therapy.

[Distinctions of petroclival meningioma with perifocal edema on adjacent brain stem]

Although the most frequent benign tumor of the central nervous system, meningioma may be associated with extensive peritumoral edema. Whereas, peritumoral edema in the brain stem along the tumor in the infratentorial region has not been given sufficient recognition. Among 44 meningiomas attached to the petrous bone, 25 cerebellopontine angle meningiomas and 17 petroclival meningiomas, peritumoral edema in the brain stem along the tumor were clearly demonstrated on T2 weighted images of MRI in three petroclival meningiomas (6.8% of all clival and 17.6% of petroclival meningiomas). Attempts were made to surgically remove all of these tumors. However, during surgery an arachnoid/pial layer between the tumor and brain stem was destroyed completely and small perforating arteries were found to be encased in the tumor at the level of the associated edema. So surgical dissection of the tumors from the brain stem was quite difficult. By attempting radical removal of the tumor in the first case, even meticulous dissections caused direct surgical damage in the brain stem due to the obliteration of small perforating vessels. In the second case, a thin layer of the tumor remnant beside the brain stem was left intentionally, but a severe damage of the brain stem also occurred due to the obliteration of small perforating vessels. In the third case, only bulk reduction of the tumor was attempted to minimize the mass effect to the brain stem and the tumor located beside the brain stem with edema and encasing the cranial nerves and the perforating arteries from the vertebrobasilar artery was left untouched. This surgical attempt caused a transient worsening of a swallowing disturbance, but was not associated with the brain stem damage in this case. In meningiomas attached to the clivus, existence of associated peritumoral edema in the adjacent brain stem on T2 weighted images on MRI may be caused by the destruction of a arachnoid/pial layer and the encasement of small perforating vessels. The attempt at tumor dissection from the brain stem at the level of the edema was very difficult and led to serious surgical complications due to direct damage to the brain stem. In such cases, the surgery should aim at achieving a simple bulk reduction and the tumor beside the brain stem with edema should be left untouched.

[Surgical approach for cervical dumbbell type neurinoma: posterior approach by partial hemilaminectomy with preservation of a facet joint]

We report on a case harboring a cervical dumbbell type neurinoma. The tumor was completely removed by a modified posterior approach, consisting of partial hemilaminectomies of C2 and C3 with preservation of the facet joint. The operative field under microscope was limited by the preserved facet joint of C2/3. However, sufficient bulk reduction of the epidural and paravertebral mass enabled us to obtain a good operative field. The paravertebral mass, which extended anteriorly to just beside the posterior aspect of the carotid sheath, was removed through the lateral space. The operative field was easily widened beside the right facet joint of C2/3 with partial removal of the posterior part of the transverse process of C2 and C3. The transit portion of the tumor to the normal nerve fiber was also identified through this space. The intracanalicular mass was removed by the partial hemilaminectomies of C2 and C3 without compressing the dural sac. Following sufficient reduction of the bulk, the right vertebral artery was identified at the anteromedial margin of the enlarged intervertebral foramen. Finally the intradural part of the tumor was removed through this space. Our modified posterior approach is a less invasive method to the bony elements of the cervical vertebrae and may minimize the incidence of postoperative instability and angular deformity. This approach also eliminates the necessity of long postoperative immobilization using a rigid cervicothoracic brace.

[Hearing preservation and tinnitus following removal of acoustic neurinomas]

Thirty-five cases of unilateral acoustic neurinomas were analyzed with special reference to the postoperative eighth cranial nerve function. An additional three cases of bilateral acoustic neurinomas associated with neurofibromatosis were also analyzed. Out of a total of 40 neurinomas in all, 38 cases were retrospectively reviewed. The thirty-five cases of unilateral acoustic neurinomas were summarized as follows. The patients' age ranged from 23 to 69 years old. The tumor size varied as follows; 7 cases were confined to the internal acoustic meatus, 4 cases were 20 mm or less in their maximum diameter, 13 cases were 30 mm or less, and 11 cases were more than 30 mm. The consistency of the tumor was classified as being solid in 27 cases, and being cystic in 8 cases. Hearing had been maintained in 27 cases on admission, serviceable in 17 cases, unserviceable in 10 cases and deaf in 8 cases. Operations were performed via the retromastoid suboccipital approach in all cases. The facial nerve was anatomically preserved in all cases. On the other hand, the cochlear nerve was anatomically preserved in 14 out of 35 cases (40%). The preservation ratio of the cochlear nerve showed a negative correlation to the tumor size. In 17 cases with preoperative serviceable hearing, preservation of the cochlear nerve was attempted, which resulted in a 65% anatomical preservation. However, hearing was preserved in 4 cases (36%). Serviceable hearing was preserved in only 2 cases. Tinnitus developed in 20 cases preoperatively, and then occurred postoperatively in 11 cases. Tinnitus was prominently aggravated in 2 cases in which the cochlear nerves were preserved, which resulted in unserviceable hearing. There was a statistically significant correlation between cochlear nerve preservation and the postoperative presence of tinnitus (Fisher's exact probability test: P = 0.0106 < 0.05). Tinnitus was aggravated just after the operation. However, it gradually improved and vanished as the hearing showed a recovery to a slight degree in one case. Three cases of bilateral acoustic neurinomas in neurofibromatosis were also summarized. One case received the operation only on the unilateral side. The remaining two cases were operated bilaterally. To preserve serviceable hearing on at least one side, partial removal of the tumor was performed under the monitoring of auditory brain stem response and/or cochlear microphonic potential. Serviceable hearing on at least one side was maintained in all three cases. In conclusion, hearing preservation can be expected after removal of the acoustic neurinomas under the following situations; hearing acuity of less than 50-60dB in preoperative pure tone audiogram, tumor size of less than 20 mm in maximum diameter, cases with preservation of cochlear nerve and of the internal auditory artery during the operation, and no injury to the labyrinth during the operation. In some cases, tinnitus becomes aggravated in the case with cochlear nerve preservation associated with unserviceable hearing. Furthermore, the degree of tinnitus shows a decrease as postoperative hearing improves in some cases.

[Prognosis after total removal of craniopharyngiomas via the frontobasal interhemispheric approach]

Prognosis after total removal of craniopharyngiomas via the frontobasal interhemispheric approach is reviewed. Seventeen patients with craniopharyngiomas were operated on in Sapporo Medical University Hospital between January, 1985 and December, 1993. In eleven patients, lamina terminalis was incised and in the last six patients, it was left intact. Tumors were completely resected in all patients. After removal of the tumor, hypothalmic--pituitary functions, visual functions and psychometric functions were examined. Two of the 17 cases showed hypernaturemia and fourteen (82%) had permanent DI. Fourteen patients are receiving DDAVP and all are receiving endocrine replacement. Of fourteen patients who had disturbance of their visual acuity, nine (64%) improved. Five of six patients (83%) who presented visual field defect showed improvement in their deficits. Thirteen patients had a psychometric assessment at the time of follow-up examination. Full-scale intelligence quotient scores were distributed as follows: three above 120, five between 90 and 109, three between 70 and 79 and two below 69. Four (32%) had some impairment of memory. Concerning the QOL after total removal of craniopharyngiomas via the frontobasal interhemispheric approach, thirteen patients (76%) are leading normal lives, and three (18%) are leading nearly normal lives but require some help to overcome mild deficits. One (6%) has suffered a significant handicap.

[Clinicopathological findings in symptomatic Rathke's cleft cyst: correlation between enhancement effects on MRI and histopathology of the cyst wall]

We have studied MR images and the histopathology of eight patients with symptomatic Rathke's cleft cysts. Six cases showed visual disturbance and two showed galactorrhea. In five, the cyst fluid had low signal intensity on T1-weighted images and high intensity on T2-weighted images; in 2, the cyst fluid had high intensity on both T1 and T2-weighted images; in 1, the cyst fluid had high intensity on T1-weighted images and low intensity on T2-weighted images. Enhancement of the cyst wall by Gd-DTPA was able to be distinguished in six cases: two patients showed no enhancement, two showed thin enhancement and the remaining two, thick enhancement. Fluid aspiration and total resection of the cyst wall was performed in all patients (three cases by the transcranial approach and five by the transsphenoidal approach). Normal pituitary glands were found in all cases during the operations. Histopathologically, ciliated epithelium with goblet cells was recognized in three cases. Non-ciliated epithelium was recognized in the other five. Stratified squamous component was recognized in one case and secondary inflammation, in another. Normal pituitary tissue was recognized in five cases. Immunohistochemically, ciliated and non-ciliated epithelium was successfully stained for detecting antibody against epithelial membrane antigen and/or carcinoembryonic antigen. Two cases with no enhancement of the cyst wall by Gd-DTPA showed only ciliated epithelium. Two cases with thin enhancement of the cyst wall had single layer epithelium with normal pituitary tissue. Two cases with thick enhancement of the cyst wall showed single layer epithelium with its stratified squamous component or with secondary inflammation. A close relationship was suggested between the enhancement effect on MRI and histopathology of the cyst wall.

Radiation induced intracranial leiomyosarcoma: its histopathological features

This is a case of intracranial sarcoma which was recognized 23 years after irradiation therapy for pituitary adenoma. Four operations were performed because of recurrences with a short interval between each operation. Immunohistochemically, the tumour cells were stained for smooth muscle actin, human muscle actin and vimentin. It was verified as a leiomyosarcoma. This report is the first case of intracranial leiomyosarcoma associated with radiation therapy in pituitary adenoma.

A case of calcification of the cervical ligamentum flavum

We report a case of cervical myelopathy caused by the calcification of the cervical ligamentum flavum. A 42-year-old woman with gait disturbance and an episode of dysuria was transferred to our hospital on June 30, 1994. Neurological examination revealed only a mild right hemiparesis. A plain neck X-ray and a tomogram revealed a nodular calcification in the posterior part of the spinal canal at the level of C5/6. Three dimensional computed tomography clearly demonstrated that the mass consisted of three nodular structures on the vertebral lamina. Magnetic resonance images demonstrated severe compression of the spinal cord by the mass whose intensity was low. The mass was removed en bloc together with the ligamentum flavum and C5 and C6 lamina. The mass showed no continuity to the dura mater. The calcification was confined within the ligament. The patient's neurological deficits were resolved two weeks after the surgery. X-ray diffraction study demonstrated the component of the mass was found to be pure hydroxyapatite. Clinical features of calcification of the ligamentum flavum are reviewed from 85 reported cases including ours, and the difference between this calcification and the ossification of the ligament is emphasized. Calcification of the ligamentum flaum is a distinct clinical entity.

[Bleeding from unruptured dissecting aneurysm in the vertebral artery after proximal clipping]

This is a case report of a patient with unruptured dissecting aneurysm in the vertebral artery that bled after being treated by proximal clipping. A 53-year-old male was admitted to our hospital due to transient right hemiparesis which occurred 20 days prior to his admission. He had been medicated for hypertension for the previous 33 years. CT scan and MRI showed lacunar infarction in the left corona radiata, and an aneurysm was accompanied with clot in the prepontine cistern. Angiography revealed a dissecting aneurysm in the right intracranial vertebral artery. His right hemiparesis was derived from infarction in the left corona radiata. It was likely that the dissecting aneurysm might rupture in the future. Proximal clip ping was performed to prevent rupture of the aneurysm. After clipping of the right vertebral artery distal to the PICA, the wall of the aneurysm appeared to be drawn toward the clip blades and to be tensed by the blades. Four hours after the operation, he complained of severe headache, and experienced a sudden loss of consciousness and the immediate development of a deep comatose state. CT scan disclosed massive SAH in the right cerebellopontine and basal cistern. Repeat angiography demonstrated that the aneurysm was not visualized and the right vertebral artery distal to the aneurysms was opacified through the left vertebral artery. Ventricular drainage was performed, but the patient died on the 20th day after bleeding. It was suspected that the aneurysmal clip might have produced shear force on the weak adventitia of the dissecting aneurysms and that the intra-aneurysmal pressure might have increased because of blood back-flow via the contralateral vertebral artery after the proximal clipping.

[Spinal intradural arachnoid cyst associated with enlarged filum terminale]

This is a report of a spinal intradural arachnoid cyst associated with an enlarged filum terminale. A 9-year-old female was admitted to our hospital complaining of lumbosacral pain. Neurological examination revealed no abnormal findings. CT scan showed a round shaped mass lesion in the right dorsolateral side of the spinal canal between the level of L1 to S1/2. The mass lesion disclosed isodensity and was not enhanced. A small low density mass lesion was visualized in the dural sac at the same level. MRI showed the mass lesion with low signal intensity on the T1-weighted image, and high signal intensity on the T2. The small mass lesion in the dural sac was demonstrated with low signal intensity on the T1 and T2-weighted image. In addition to this finding, Chiari malformation type I was disclosed. It was suspected that this mass lesion was extradural arachnoid cyst associated with an enlarged filum terminale. Osteoplastic laminotomy between L3 to S1/2 was performed, and an arachnoid cyst was found in the intradural space. It compressed the cauda equina and enlarged tough filum terminale. The cyst was removed subtotally, and the filum terminale was cut off. Postoperative course was uneventful and the lumbosacral pain disappeared. It was thought that this pain might be derived from the intradural arachnoid cyst, or the enlarged filum terminale.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of systemic lupus erythematosus associated with cerebral infarction and cerebral hemorrhage]

This is a report of cerebral infarction and cerebral hemorrhage derived from systemic lupus erythematosus. A 49-year-old male was admitted to our hospital due to dysarthria and supranuclear facial palsy. He had been suffering from SLE and medicated incompletely since 9 years prior to admission. A CT scan showed a small infarction in the left parietal area. An angiography revealed a tapering stenosis of the left carotid siphon and an occlusion of the left vertebral artery at the cisternal portion. On the 13 days after the admission, he complained of a high fever and right hemiparesis. The CT scan disclosed newly multiple small infarctions in the left parietal area. The angiography showed the progressing of the tapering stenosis at the left carotid siphon, and demonstrated the narrowing of the left superior temporal artery and ophthalmic artery in addition to the disappearance of a left posterior communicating artery. High dose of steroid was given to him, but cerebral hemorrhage and huge left cerebral infarction were complicated. On the 26 days after the admission, his general condition was worsened and died. It was considered that the cerebral infarction and hemorrhage might be derived from the vasculitis of SLE.