Keiichi Kuwamura

Saccular aneurysm arising from a fenestrated anterior cerebral artery.

The authors report a case of fenestrated anterior cerebral artery associated with a saccular aneurysm at its proximal end. The significance of this anomaly is briefly discussed with regard to the genesis of anterior cerebral artery aneurysm.

Meningioma in the interpeduncular cistern in a child

The authors describe an 8-year-old boy who presented with progressive oculomotor palsy on the left side. The diagnostic evaluation with computerized transmission tomography (CTT), metrizamide CTT cisternography, and angiography indicated an extra-axial tumor in the left interpeduncular cistern, extending into the suprasellar and prepontine cisterns. A meningioma was demonstrated with attachment only to the interpeduncular portion of the left oculomotor nerve. The patient was treated successfully by complete removal through a pterional approach.

Reversible congruous homonymous hemianopia as a symptom of shunt malfunction.

Congruous left homonymous hemianopia occurred as a symptom of ventriculoperitoneal shunt malfunction. The low attenuation along the ventricular catheter in the right occipital area that was seen on a computed tomography scan disappeared after revision of the shunt, and corresponded with improvement of this peculiar visual field symptom. In view of anatomic considerations and clinical course, this homonymous field defect might be caused by peritubular cerebrospinal fluid edema in the right occipital area. In evaluating the patients having shunts, precise neuroophthalmologic examination should be performed for possible visual field defects.

Delayed onset massive oedema and deterioration in traumatic brain injury.

A 52-year-old man fell from standing and a computed tomography (CT) scan revealed traumatic intracerebral haematoma and subarachnoid haemorrhage in the temporal cortex. He was treated without surgery and discharged. On day 30 after the accident, he had no neurological deficit. On day 37 he complained of headache and urinary incontinence, and on day 39 he was hospitalized due to progressive neurological deterioration (reduced conciousness, dilated pupils, and left hemiplegia). A CT scan revealed a diffuse low-density in the right cerebral hemisphere with marked midline shift. Emergency decompressive craniectomy and right temporal lobectomy were performed. Angiography after surgery revealed moderate vasospasm in the right middle and anterior cerebral arteries. The patient remained severely disabled. Delayed onset neurological deterioration can be caused by brain oedema and vasospasm after traumatic brain injury, despite an intervening period of improvement.

Syrinx-fourth ventricle and lateral ventricle-peritoneal shunts for congenital hydrocephalus with syringobulbia and syringomyelia: Case report

A case of congenital hydrocephalus with syringobulbia and syringomyelia was reported. Although his neurological condition had deteriorated because of shunt malfunction, progressing syringobulbia, and syringomyelia, he recovered because of the direct communication from the syrinx in the medulla to the fourth ventricle, the shunt from the syrinx in the cervical spinal cord to the fourth ventricle, and the lateral ventriculoperitoneal shunt.

Treatment of early recurrent medulloblastoma in children with cisplatin and etoposide: a preliminary report

The prognosis of recurrent medulloblastoma remains extremely poor. Combination chemotherapy with cisplatin (CDDP) and etoposide (VP-16) was given to five children with early recurrent medulloblastoma. As a rule, CDDP 20 mg/m2 per day and VP-16 60 mg/m2 per day were administered intravenously for 5 days. This cycle was repeated three times at 4-week intervals. After this therapy, cerebellar signs improved in one case and were unchanged in four cases. Weakness and sensory disturbance, however, improved in three of four patients. Moreover, neck and/or back pain resolved in all these four. Radiological findings improved in three cases. Myelosuppression appeared in all patients, but receded rapidly. No other significant complications were noticed. Two patients died 5 and 6 months after this therapy. There results seem to suggest that this therapy has a use in improving neurological symptoms, particularly neck and/or back pain, although its efficacy is limited.

Tumors of the Central Nervous System in Children under 2 Years of Age

This report reviews our experience with 52 cases of intracranial tumors in children under 2 years of age observed and treated in the Neurosurgical Department, Childrens Memorial Hospital, Chicago and in the Department of Neurosurgery, Kobe University Hospital, in Kobe, Japan from 1962 to 1975. All tumors were diagnosed histologically under 2 years of age except for one case of so-called unverified glioma. The youngest was 4 days of age and the oldest was 24 months of age. 9 patients were newborn, 24 infants and 19 toddlers. There were 32 boys and 20 girls. The location of tumors of children under 1 year of age were predominantly in the supratentorial area. More astrocytoma (29%) were found than medulloblastoma (19%), optic glioma (15%), ependymoma (8%) or choroid plexus papilloma (8%). Pathohistological characteristics were the extensive tumor invasions. Especially in neonatal brain tumors, inmature cells, rapid tumor growth and high malignancy were the most frequent findings. Since most brain tumors in early life were located along the cerebral axis, obstruction of cerebrospinal fluid circulation that resulted in hydrocephalus was the most common clinical finding. Enlarged head, vomiting and irritability were the cardinal symptoms. The younger the infant, the greater the incidences of increased head sizes, and the older infants and toddlers showed higher incidences of vomiting and irritability. Bobbing of the head was observed in 2 cases, one with a large craniopharyngioma and the other with a choroid plexus papilloma of the third ventricle. Forty-five patients underwent primary surgery for tumor removal. Out of 45 cases of hydrocephalic infants, 29 cases were treated with shunting procedures either after or before primary surgery. Our present approach for hydrocephalus due to the intracranial tumors is to stage our procedures so that the initial shunting operation is followed in one or two weeks by definitive surgical attack. Radiation therapies were conducted in 27 cases (51 %) including one case of highly vascular tumor of a deep cerebrum which was treated by radiation therapy alone. Seven cases had chemotherapy. Twenty-three patients had steroid therapy pre and post-operatively. Five of these, all with posterior fossa tumors, suffered gastrointestinal hemorrhage. None of the patients who did not receive steriod therapy developed gastrointestinal bleeding. In 45 cases, which were available for follow-up study, 19 cases (42.2%) expired in 3 months postoperatively. The longest survival, 11 years, was in a child with a choroid plexus papilloma of the lateral ventricle. Absolute 2-year survival of sarcoma was 75%, optic glioma 60%, astrocytoma 61.5%, ependymoma 33% and medulloblastoma 0%. Out of 7 cases of medulloblastoma available for follow-up, 6 patients expired in 3 months after primary surgery. The prognosis of the medulloblastoma under 2 years of age was extremely poor.

Detection of delayed cerebral vasospasm by MR angiography

MRA was useful in detecting cerebral vasospasm after subarachnoid haemorrhage. We carried out experiments by performing MRA with a clip placed inside the coil of the imager, and observed neither heat generation nor displacement of the clip.

Magnetic Resonance Angiography in Occlusive Cerebrovascular Disease

Based upon the experiences of approximately 1500 patients examined by magnetic resonance angiography (MRA) at Hyogo Prefectural Awaji Hospital, we review here the application of MRA in the diagnosis of occlusive cerebrovascular disease in both the acute and chronic stage. MRA is useful not only in routine outpatient screening examinations but also in guiding the treatment of strokes in the acute stage by localizing the site of vessel obstruction more precisely and identifying areas of stenosis. The results of this study show that conventional cerebral angiography and MRA are in close agreement in the diagnosis of cerebral vasospasm after subarachnoid hemorrhage. Clip artifacts interfered with the assessment of some vascular regions around the surgical clips. MRA is an effective tool for detecting cerebral vasospasm after clipping procedures for cerebral aneurysm.

Epidemiological Aspect of Chronic Subdural Haematoma

The epidemiological study for chronic subdural haematoma (CSH) in the elderly over 65 years old, was done in Awaji Island having about 170,000 inhabitants. Since the Island is surrounded by inland-sea and our department is the only one neurosurgical service, we could make the statistical analysis for occurences of CSH.