[A case of chondromyxoid fibroma of the frontal bone]

A case of chondromyxoid fibroma of the skull is reported. A 20-year-old boy visited our clinic on December, 1982 because of a recurrent forehead tumor. He had a 4 X 4 X 1.5 cm tumor on the right side of forehead and a 3 X 3 X 0.5 cm tumor on the left. Neurological examination showed no abnormalities. Skull X-ray film showed a large round radiolucent area with clear sclerotic margin in the frontal bone and right orbit. Right carotid angiogram showed marked posterior displacement of the anterior cerebral artery, but no tumor stain. Plain CT scan showed a mass with iso to low density area in the frontal region. It was markedly and irregularly enhanced with contrast media. Surgery was performed entirely in the epidural space, and the tumor was completely removed. The post-operative clinical course was uneventful. Histologically, the three components of chondroid, myxomatous and fibrous tissues in this tumor led to the diagnosis of "chondromyxoid fibroma."

[An autopsy case of intracranial multiple meningiomas associated with extracranial multiple neurinomas]

An autopsy case of intracranial multiple meningiomas associated with extracranial multiple neurinomas was presented. A 55-year-old woman, who had received surgical treatment for right parasagittal meningioma 20 years ago, gradually showed the sign of increased intracranial pressure and disturbance of the lower cranial nerves. Brain CT scan demonstrated numerous intracranial tumors. At autopsy 124 intracranial meningiomas, and neurinomas in her left cervical and right axillar portion were found. Meningiomas showed the transitional and fibroblastic type, histopathologically, and axillary and cervical tumors were the Antoni A type neurinomas. It is suggested that this case had a tendency of heterogenous and multiple origination of tumors.

[Case of postoperative subdural tension pneumocephalus]

In this paper, a case with subdural tension pneumocephalus secondary to bifrontal craniotomy and VP shunt for ruptured Acom aneurysm is reported. In this patient, the mechanisms for entry of air into the subdural space and producing mass effect (Tension pneumocephalus) seem to be one way valve mechanism and negative pressure due to excess of CSF drainage owing to shunting system. Only 29 reported cases of tension pneumocephalus following surgery were found in an extensive review of the literature. We discussed about the clinical symptoms and signs, therapy, and especially about the mechanisms leading to this condition, and prevention for it.

[Direct surgical obliteration of a persistent trigeminal artery aneurysm]

A successful case of ruptured aneurysm of the persistent trigeminal artery (PTA) treated with direct operation is reported. Only 14 cases out of ever-reported 400 cases with persistent trigeminal artery have aneurysms developing from PTA itself or its junction. These aneurysms originate most frequently from the trunk portion of the PTA. In our case, aneurysms are found at the rt. internal carotid-PTA junction and the rt. IC-PC junction. Six out of 14 are associated with another intracranial aneurysms, indicating high multiplicity. Of 14 cases, only 2 including our case are treated by direct surgery. Since the internal carotid-PTA junction aneurysm is located in the cavernous sinus, special consideration is needed during the operation. Surgical keypoints in opening the cavernous sinus under normothermia and getting the landmark for orientation are described.

The development of spontaneous body movement in prenatal and perinatal mice

The qualitative and quantitative changes in behavioral development in the prenatal and perinatal periods have been insufficiently studied. We observed the occurrence of spontaneous body movements in three strains of mice (ICR, C3H, and BALB) and the pulse counts measured by EMG activity gestation period normal for mice. During the prenatal period, fetal movements changed from simple movements to complex and coordinated movements. Differences in the timing of the development of these movements were not found in the three strains of mice. During the perinatal period, the three kinds of simple movement decreased. This decrease was affected by the onset of pulmonary respiration after delivery. The time span of spontaneous movement did not change during the perinatal period, while the pulse counts measured by EMG activity increased with age.

Acoustic neurinoma presenting as subarachnoid hemorrhage

A 49-year-old man who had been suffering from disturbance of hearing for 5 years suddenly developed severe headache, nausea, and vomiting. Computed tomography (CT) scans both with and without contrast medium enhancement, performed on the day of admission, showed a nearly round high-density area in the left cerebellopontine angle. A left transaxillary vertebral angiogram showed no aneurysm or arteriovenous malformation. Hemorrhage from a tumor in the left cerebellopontine angle was suspected. CT scan without contrast medium enhancement, performed on the 17th day after onset, showed only a small, ill-defined high-density area in the cerebellopontine angle. An operation was performed on the 20th day after onset. The tumor was totally extirpated together with a clot. Histologically the tumor was an acoustic neurinoma with hemorrhage and necrosis. The postoperative course was favorable. Massive hemorrhage from primary intracranial tumors, especially acoustic neurinomas, is discussed. Radical operation on the tumor should be performed as soon as possible.

[Villaret's syndrome due to extra-cranial internal carotid aneurysm: a case report]

A 69 year-old male was admitted to our clinic with the chief complaint of hoarseness and difficulty in swallowing. These symptoms occurred about 5 months after penetrating neck injury. Neurological examination revealed right ninth to twelfth cranial nerves palsy and Horner's syndrome. Plain skull X-P demonstrated two broken pieces of glass below the right mastoid processus. The right carotid angiogram showed a 45 x 25 mm aneurysm originated from the right internal carotid artery just below the carotid canal. As the first operation, gradual occlusion of right internal carotid artery combined with the right STA-MCA anastomosis was performed. But two days after complete occlusion, left hemiparesis and pseudobulbar palsy appeared. Two months after such episode, aneurysm and the pieces of glass were removed. He discharged on foot with the improvement of the symptoms of lower cranial nerves. Villaret's syndrome caused by the traumatic aneurysm of extracranial internal carotid artery is rare. This case seems to be the first report in Japan.

Moyamoya disease--a review

One hundred cases of Moyamoya disease were encountered between 1961 and 1980. This report describes the clinical characteristics and emphasizes the angiographic findings and clinical correlation in this disease. Reasons for the differences in clinical and radiological presentation in children versus adults are proposed and a possible pathophysiological mechanism is outlined. Treatment with perivascular sympathectomy and superior cervical ganglionectomy may be useful but more investigation needs to be carried out into the pathogenesis of the disease before more definitive therapy is realized.

[Development of a new therapeutic method of brain infarction in the acute period: revascularization under the administration of mannitol and perfluorochemicals]

Ten cases were treated with systematic administration of mannitol followed by the blood substitute, perfluorochemicals, in the acute period of cerebral infarction in order to suppress the development of infarction and progressive deterioration. This chemotherapy was followed by reconstructive vascular surgery. There were 8 cases of cerebral infarction and 2 other cases in which cerebral vascular occlusion occurred during surgery. Due to this treatment, there were no cases of aggravated condition or death and at the time of follow-up examination after 2 months, and 8 of the ten patients returned to productive lives. We consequently believe that this therapeutic method may prove to be the effective means for treating cerebral infarction in the acute period. It is also thought that this method is applicable in surgical cases where long-term vascular occlusion is required.

[Sibling case of osteosclerosis with cranial nerve symptoms]

We experienced two cases of "Osteosclerosis" who were 12 and 15 year old sisters. Previous reported cases of this disease are 50 cases and among them only one patient was reported in Japan. Osteosclerosis seems to be inherited as an autosomal recessive trait. Parental consanguinity is also observed. The peculiar facies are evident in infancy, characterized by broad, flat nasal bridge, ocular hypertelorism and prognathic, broadened mandible. Commonly, they have cutaneous syndactylies in bilateral hands and feet, especially between the second and third finger and toe. Roentgenographically, hyperostosis with osteosclerosis can be observed in systemic bones, particularly the calvarium is greatly thickened. Since such a bony change occurs most severely at the base of the skull, important clinical symptoms of this disease are cranial nerve palsies resulting from obliterations of unilateral or bilateral several cranial nerve foramina. In many cases deafness due to progressive encroachment upon the middle ear cavities and auditory nerve canals appears early in infancy. Transient palsy of the facial nerve occurs somewhat later, and bilateral facial paralyses are usually permanent in adulthood. In some cases optic atrophy and visual field defect due to compression of the optic nerves are late complications. Other ocular symptoms are strabismus, nystagmus and exophthalmos. Anosmia and trigeminal nerve palsy are less common. Lower cranial nerve symptoms can not be noted but the reason is unclear. Chronic headache, convulsion and mental retardation are occasionally present. They are considered as a result from increased intracranial pressure due to progressive diminution of the cranial capacity. By same mechanism, several patients have died suddenly from impaction of the medulla oblongata in the foramen magnum in early adulthood. Then, some reporter puts emphasis on prophylactic opening of the foramen magnum in all adult cases.

A new therapeutic method for acute brain infarction: revascularization following the administration of mannitol and perfluorochemicals--a preliminary report

Ten patients were treated with systemic administration of mannitol followed by blood substitute (perfluorochemicals) in the acute period of cerebral infarction in order to suppress the development of infarction and progressive deterioration. This chemotherapy was followed by reconstructive vascular surgery. There were 8 patients with cerebral infarction and 2 others in whom cerebral vascular occlusion occurred during an operation. Due to this treatment, there was no case in which the patient's condition was aggravated or in which death occurred. At examination two months later, 8 of the 10 patients had returned to productive lives. We consequently believe that this therapeutic method may prove to be an effective means of treating cerebral infarction in the acute stage. It is also thought that this method is applicable in surgical cases in which long-term vascular occlusion is required.

[A case of radiation necrosis with vascular changes on main cerebral arteries (author's transl)]

A 64-year-old woman had received radiotherapy, following surgery of a chromophobe pituitary adenoma. Six years after irradiation she began to complain of headache and dementia. Right vertebrogram demonstrated a right temporal mass lesion, stenosis and dilatation of middle cerebral artery and posterior, communicating artery in the field of irradiation. CT scan showed the irregular low density area at the right temporal region, and the irregular enhancement after an intravenous injection of contrast medium was seen at the small part of affected area. From these findings, radiation necrosis at the right temporal lobe was diagnosed. As vascular changes of the main cerebral arteries due to radiation are rare, we discussed on them from ever reported literature.

[Sleep in vegetative state patients and recuperated cases from vegetative states (author's transl)]

Twenty-four hours polygraphic recording of EEG, electrooculogram and EMG were performed on 8 vegetative state patients and 4 recuperated cases, and the differences of the sleep pattern between two groups were discussed. It was difficult to divide the sleep pattern into normal four stages, because the frequency of EEG in vegetative state patients were very slow. So we divided it into the following 4 patterns; awake, shallow sleep, deep sleep and REM sleep. The sleep in vegetative state patients was interrupted by short duration and appeared at random during day and night. The amount of sleep in vegetative state patients increased proportion to severity of vegetative state. Rate of shallow sleep of them was high. REM sleep was seen in all the cases, but its cycle and lasting time were different in each case. The rate of shallow sleep prior to REM sleep was lower than normal pattern and the change of sleep state was atypical. Few hump and spindle wave appeared. For the reasons mentioned above, the sleep pattern in vegetative state patients was far from physiological sleep. On the other hand, the sleep in recuperated patients was more similar to the normal pattern than that of vegetative cases, but the rate of shallow sleep was as high as the vegetative cases. REM sleep was irregular and the change of sleep was also atypical. Therefore, the sleep pattern in recuperated patients was also far from physiological sleep, though it was better than that of vegetative cases.

[Long term survival of holoprosencephaly with shunting procedure (author's transl)]

A long survived case of holoprosencephaly with hydrocephalus has been infrequently reported in the literature. One such case were presented on this report. This male baby by cesarean section because of his large head circumferenced 45 cm. He was admitted to our clinic diagnosed as congenital hydrocephalus at the third day from birth. On admission the circumference of his head was measured 49 cm, but other external malformations were not noticed. Right transaxillary carotid angiogram showed anterior cerebral artery appeared like azygos anterior cerebral artery. Absence of falx and fornix were suspected pneumoventriculography and transillumination of the head. Finally he was diagnosed as holoprosencephaly accompanied with hydrocephalus by computed tomography. Ventriculo-peritoneal shunt was performed at the 22nd day of his life. On follow-up after discharge, mental and motor development was not so poor. He was able to speak a few of simple words one year after discharge. At present 4 years and 6 months after discharge, he can do simple conversation and walk with assistance. Repeated computed tomography shows the frontal cerebral mantle is thickening in 36 mm at present. Good resulted case of holoprosencephaly as presented here could not be found in the literature. The pathogenesis and treatment were also discussed here.

[A case of acoustic neurinoma simulating subarachnoid hemorrhage (author's transl)]

A 49-year-old male, who had been suffering from left hearing disturbance before 5 years, suddenly developed severe headache, nausea and vomiting on January 3, 1979. Both plain and enhanced CT performed on the day of admission showed a nearly round high density area at the left cerebello-pontine angle. The left trans-axillary VAG showed no aneurysm or AVM. From the above-mentioned course and findings, hemorrhage from a tumor of the left c-p angle was suspected, but considering the size of the high density area, radical operation was considered to be contraindicated and v-p shunt operation was performed. However, plain CT performed on January 19th, showed only a small, ill-defined high density area at the c-p angle. The tumor was quite large, but considered to be operable, so that excision was performed on January 22nd. The tumor, 5 X 5 X 4 cm in size, was totally extirpated together with the clot. Histologically the tumor was acoustic neurinoma with hemorrhage and necrosis. Postoperative course was favorable. We discussed the massive hemorrhage from primary intracranial tumors, especially acoustic neurinoma. Radical operation on the tumor should be performed as early as possible, provided that the patient's condition permits.

[An operated case of foramen magnum neurinoma (author's transl)]

A 36-year-old male with craniospinal type of foramen magnum neurinoma removed totally was reported. Foramen magnum neurinoma shows various clinical symptoms called foramen magnum syndrome but none of them is specific. Therefore almost all the cases in the literature have been misdiagnosed as degenerative or demyelinating diseases. The best way for correct diagnosis is to suspect the existence of the tumor. Conventional suboccipital craniectomy has been adopted to remove the tumors. But craniospinal type of this tumor usually develops in the anterior part of the foramen magnum. Therefore we approached to the tumor from aside in the lateral position. In this approach, we can avoid tissue damage of cerebellum and medulla due to retraction and can reach near the midportion of the posterior fossa. The importance of checking respiration during surgery is also emphasized, because surgical intervention is carried out around the medulla oblongata.

[Transdural anastomosis in moyamoya disease--vault moyamoy (author's transl)]

Transdural anastomosis in Moyamoya disease, which we have named as "Vault Moyamoya", is reported. It seems that these vault moyamoya vessels are apt to be developed at certain fixed positions; 9 definite places in children cases 6 in adults. Main feeding arteries of each vault moyamoya are dural arteries. In addition to them, the blood flow from STA and OA is found. The incidence of vault moyamoya at each position shows similar tendency both in children and adults cases. Vault moyamoya are developed more frequently around the base of the brain near the carotid fork, where occlusion exists. Less moyamoya are formed as the position is farther from the carotid fork. In children, the incidence of vault moyamoya seems to coincide with the phases of basal moyamoya. It is not clarified yet whether the adults vault moyamoya are straightly inherited from children vault moyamoya. Blood flow from vault moyamoya to the brain cannot be ignored. When STA-MCA anastomosis is applied to moyamoya cases, we had better take the degree of development and positions of vault moyamoya into consideration, because we have to cut STA and MMA in the procedure.

[An operated case of giant pituitary adenoma (author's transl)]

A case of giant pituitary adenoma was reported. The patient was a 47-year-old man with visual disturbance. CT scan revealed the huge tumor, about 6 cm in diameter, at the midportion over the sella turcica, extending to the frontal, temporal, posterior and hypothalamic region. Total resection of the tumor was successfully carried out and the difficult post-operative complications were overcome. In this paper we mainly discussed the operative procedure for giant pituitary region tumor, which usually involve the main cerebral arteries, i.e., A1 and A2 portion of the anterior cerebral artery (ACA), anterior communicating artery (ACOMA) and intracranial internal carotid artery (ICA). We used to expose the internal carotid artery at the neck for the temporary occlusion prior to craniotomy. Prolongation of the temporary occlusion time is achieved by intravenous administration of 800 ml-20% mannitol solution. After bifrontal craniotomy, we approach the tumor interhemispherically and expose the A2 portion of ACA. Then anterior communicating artery, A1 portion of ACA and ICA are exposed as the tumor is extirpated. Under the bifrontal craniotomy, as we separate bilateral Sylvian fissure and interhemisphere, we can get the wide operative field and we can also approach the tumor from various direction. Therefore, even the tumor is huge, it is possible to remove the tumor without brain damage, vessel and cranial nerve injury.

[Surgery of orbital tumor--analysis of location and appropriate operative approaches (author's transl)]

Twenty-six cases of orbital tumor were operated on during the period from 1965 to August, 1978. Pseudotumor was most frequently encountered, accounting for 7 cases followed by optic glioma (5 cases), meningioma (4 cases), mixed tumor (3 cases), hemangioma (3 cases), etc. Orbital venography and CT scan were found to be useful for determination of their location and nature. Most of the orbital tumors were found in the central or upper half of the orbit (62%) in coronal section and retrobulbar position (85%) in sagittal section. Intracranial extension was found in 7 cases (27%), and in 4 cases of the 7, intracranial extension was not suspected even by detailed preoperative examination. This fact indicates the importance of opening the dura mater and inspecting the chiasmal region. We therefore have adopted a frontal intra- and extradural combined approach. Other advantages of this approach were also discussed.

[A ruptured aneurysm associated with pituitary tumor (author's transl)]

The aneurysm case associated with brain tumor is not so rare. Most of aneurysms are non-ruptured and found incidentally during the examination for brain tumor. We have experienced with 4 aneurysm cases associated with brain tumor among 1,280 aneurysm cases during these 17 years. One out of 4 cases was of ruptured aneurysm associated with pituitary tumor. This rare case and review of the literature were described.

[Spontaneous regression of a posterior fossa dural arteriovenous malformation (author's transl)]

A 29-year-old woman was admitted to our hospital because of dizziness, nausea and convulsive seizure. She complained of left sided tinnitus. Neurological examination revealed right homonymous hemianopsia, and systolic murmur on the left retroauricular area. Angiograms revealed a dural AVM in the left posterior fossa. Feeders of AVM were enlarged left occipital artery and middle meningeal artery. Since then she was treated only conservatively, but angiograms performed two years and one month later showed disappearance of the dural AVM. She experienced no head trauma, and no subarachnoidal hemorrhage. She has never been treated by irradiation nor contraceptives. We could find no clear mechanism for the spontaneous regression of the AVM.

[A case of giant choroid plexus carcinoma in a child (author's transl)]

A 1-year-and 4-month-old girl with giant choroid plesux carcinoma was reported from a viewpoint of surgical treatment. As this tumor develops in the ventricular system, rapid deterioration of the general condition due to marked intracranial hypertention is seen especially in children. Therefore, the first aid of the surgical treatment is the control of the intracranial pressure by continuous ventricular drainage in an attempt to improve the general condition of the patient. Because the tumor is very bloody, applying of the temporary clip on the feeding artery such as the anterior choroidal artery should be recommended prior to the dissection of the tumor during surgery.

[Aneurysm surgery in the older patients (author's transl)]

A series of 9 patients over 70 years of age with saccular aneurysms, operated on by a direct surgery is reviewed in order to discuss the aneurysm surgery in the older patients. The median age of the patients was 74 years, and median interval from the hemorrhage to surgery was 18 days. Operative mortality was 11% and morbidity was 33%. Result of intracranial aneurysm surgery in the older patients depends on the surgical technique for the arteriosclerosis. 1. Treatment of the aneurysm neck must be abandoned when a severe arteriosclerosis exists around it. Subsequent to exposure of the whole aneurysm, a complete reinforcement of the aneurysm wall should be undertaken. 2. Especially gentle manipulation of the brain is necessary since small arteries are easily pulled out from the sclerotic artery. 3. The cerebral veins must be preserved as well as possible to avoid the venous congestion, which easily causes an intracerebral hematoma following brain retraction. 4. The frequency of pre and postoperative complications is high, but through vigorous care, they are kept under control. 5. It is best not to judge the surgical indication simply by the chronological age, but rather to consider the physical age including the laboratory findings. Therefore, other than cases of severe arteriosclerosis, the same principles for surgical indication in younger patients should be used for older patients.

[Surgical treatment of the carotid-ophthalmic aneurysms (author's transl)]

Six cases of carotid-ophthalmic aneurysm submitted to direct operation were studied. 1. One out of six cases died postoperatively (mortality rate 16.7%). 2. Exposure of the internal carotid artery at the neck is absolutely necessary for its temporary occlusion. Temporary occlusion of the internal carotid artery at the neck makes the dissection of the aneurysmal neck easier and prevents the aneurysmal rupture during operation. 3. To cope with various complicated handlings, bifrontal carniotomy is recommended. 4. In order to make easy the dissection of the aneurysmal neck, the unroofing of the optic canal as well as the extensive removal of the tip of the anterior clinoid should be performed. 5. From our experience as well as review of the literature, the surgical result of the giant aneurysms is bad. Some new therapy is expected to be developed for the giant aneurysm of this site.

Aneurysm surgery above the eighth decade

A series of nine patients over 70 years of age with saccular aneurysms, operated on by direct surgery, is reviewed in order to discuss aneurysm surgery in older patients. The median age of the patients was 74 years, and the median interval from haemorrhage to surgery was 18 days. Operative mortality was 11%, and morbidity was 33%. Because of arteriosclerosis round the aneurysm neck and parent artery, special considerations for surgical treatment on the older patients are required.

[Surgical treatment of the internal carotid-posterior communicating artery aneurysm--from the experience of 213 cases (author's transl)]

213 cases of so-called posterior communicating artery aneurysm submitted to surgical operation without using microscope were reviewed from the technical point of view. Aneurysm project boradly to two directions, i.e. postero-inferior and lateral directions. We have treated these anuerysms with two very distinct operative approaches in order to reach the aneurysmal neck from the right angle. Frontal approach is used for the aneurysms projecting laterally. In contrast, the aneurysms projecting postero-inferior are reached laterally by mobilizing the tip of the temporal lobe. Of 213 patients, 15 died (mortality rate 7.0%) and 19 were poor (8.9%). The operative result of the cases in which the aneurysm ruptured during the exposure of the aneurysmal neck was poor. Therefore, intensive care is emphasized to avoid the aneurysm rupture during surgery. Other important technical points which affect the operative results were discussed.

Electroencephalographic findings in children with moyamoya disease

The EEG findings in 25 children with moyamoya disease were studied. Characteristic findings such as posterior slow, centrotemporal slow (CT slow), "rebuildup" after the end of hyperventilation, and sleep spindle depression were observed. Posterior slow activity was mainly observed in the EEGs examined within a short period (mean, 10 months) after onset, CI slow activity after a longer period (mean,, 28 months), and a diffuse low-voltage pattern after these periods (mean, 56 months). Buildup after the end of hyperventilation, which we refer to as "rebuildup," was discovered in more than half of the cases.

[Surgical treatment of the middle cerebral artery aneurysm--from the experiences of 174 cases (author's transl)]

174 cases of middle cerebral artery aneurysm submitted to surgical operations without using microscope were reviewed. At operation, the head is set on the neutral and slightly chin up position, not turned to any directions. Small craniotomy, which is about half as much as the ordinary unifrontal craniotomy, is performed. The merit of our method is as follows; the M1 portion (Fisher) of the middle cerebral artery runs horizontally, so that we can keep the parent artery during the operation, and owing to the chin up position the strong retraction of the frontal lobe can be avoided. Of 174 cases, 9 were dead (mortality rate 5.2%) and 18 were poor (10.4%). Bad operative outcome is due to the obstruction of the middle cerebral artery around the aneurysmal neck. Therefore, we should always keep in mind to preserve the blood flow of the parent artery as well as that of its branches. Study was made mainly on this point of view such as the general technical process of the aneurysmal neck treatment, the treatment of the cases with severe arteriosclerosis and with large aneurysms having the blood coagula inside.

[On-off mechanism of shunt system due to slit ventricle (author's transl)]

We report two cases of high shunt dependency, which were first thought to be shunt independent arrested hydrocephalus. Though their shunt systems didn't seem to work, symptoms of rapid increasing intracranial pressure were observed after obstruction or replacement of shunt tube. Their ventricles looked so small like a slit on CT scan and PVG that the apex of the ventricular tube were easily obstructed by a ventricle wall. This is the reason why we misjudged them to be shunt independent arrested hydrocephalus. The cause of slit-like ventricles was overflow of CSF fluid due to the low pressure valve and the siphon effect. In general, after the shunt operation, most of the cases with thickening of cerebral mantle show the shunt dependency. Especially the cases showing rapid and marked thickening of the cerebral mantle are highly shunt dependent. Therefore, we must observe such cases carefully, in which the ventricle becomes small. Short interval follow-ups by CT scan after the shunt operation are quite necessary in order to observe the ventricle size. Easy and reliable judging method to know whether the shunt system is working or not is required to be developed.

[Third ventriculostomy for the hydrocephalus after subarachnoid hemorrhage (author's transl)]

Twenty-eight cases after subarachnoid hemorrhage due to ruptured intracranial aneurysms was undergone third ventriculostomies as the reason that the development of postoperative CSF disturbances was determined to be highly probable. The indication and value of third ventriculostomy was discussed considering various clinical and operative findings. Postoperatively, six of the 28 cases required ventriculoperitoneal shunt operation. Although temporary disturbances of serum electrolytes was noted in three cases, no other side effects was attributed to third ventriculostomy. During hospitalization, no fatalities occured following third ventriculostomy. The addition of third ventriculostomy to surgery for ruptured intracranial aneurysms in highly recommended, especially in cases strongly indicating the possible occurrance of postoperative CSF flow disturbances.

Distribution of intracranial aneurysm

The 1,080 cases of intracranial saccular aneurysms, which were seen at our clinic during the period from June 1961 to September 1975, were subjected to the analysis on the location of the aneurysms, age distribution and sex incidence.

[Surgery of anterior communicating artery aneurysm--from the experiences of 346 cases (author's transl)]

In the past 14 years, 1000 cases of aneurysms were submitted to surgical operations without using microscope. In this report 346 cases of anterior communicating artery aneurysms were studied. The operative result at discharge was as follows; 19 cases (5.5%) were dead, 27 poor, 39 fair, 64 good and 197 excellent. In the follow-up, out of 300 cases 29 were dead (16 were related to the operation), 7 were poor, 13 fair, 26 good and 226 excellent. Out of 19 dead cases during hospitalization, 14 were operated within two weeks after SAH. Ten out of 14 cases operated within two weeks died due to vasospasm and all these 10 cases were operated between five to 11 days after SAH. These results and results of ultra-early surgery on other sites of aneurysm suggested that the surgery should be avoided on the cases from third to 10th day after SAH. After the 3rd day, the operation should be decided by taking vasospasm into consideration. If the SAH attack is a mojor one accompanying loss of consciousness more than one hour, the operation should be postponed until the 14th day. If the SAH attack is a moderate one accompanying loss of consciousness within one hour, it should be postponed until the 9th or 10th day. When the SAH attack doesn't accompany loss of consciousness, the surgery can be done any time. If stiff neck is obvious, it should be performed on the 9th or 10th day. Our approach for anterior communicating artery aneurysms is a interhemispherical approach following the bifrontal craniotomy. Hypothermic anesthesia around 27 degrees C was used in order to prolong the temporary occlusion time until 1971. Since 1972, 500 approximately 800 ml of 20% mannitol was applied intravenously for preventing the infarction following the temporary occlusion under the normothermic general anesthesia. Details of the operative records of 346 cases were analyzed and our operative method, technique and technical points were discussed.