Shinken Kuramoto

Outcome of Acute Subdural Haematoma Following Decompressive Hemicraniectomy

Retrospective analysis of 15 cases with acute subdural haematoma receiving decompressive hemicraniectomy was carried out in an effort to clarify the beneficial effect and limitation of this operative procedure. The patients in this series were divided into three groups according to postoperative intracranial pressure (ICP). Decompressive hemicraniectomy was effective in lowering ICP in all patients except for the cases that developed acute brain swelling. Overall mortality rate was 66.7% in this series. Preoperative clinical status, and intra- and postoperative ICP and CT findings obtained within 24 hours of operation were correlated with the operative outcome.

Spontaneous regression of primary malignant intracranial lymphoma

A rare case of intracranial multiple tumor, which disappeared spontaneously on serial cranial computed tomography (CT) scans, is described. The initial CT scan showed multiple, well-enhanced lesions in the right frontal and parietal lobes. The lesions disappeared spontaneously without any treatment during the 2 following months of observation. One month later, however, a newly formed tumor was found on serial CT-scanning. Surgical intervention confirmed the histologic diagnosis of a non-Hodgkins, large, and diffuse-type malignant lymphoma. The possible mechanism of temporal disappearance of tumors on CT scanning is discussed.

The outcome from acute subdural haematoma following decompressive hemicraniectomy

SummaryRetrospective analysis of 15 cases with acute subdural haematoma receiving decompressive hemicraniectomy was carried out in an effort to clarify the beneficial effect and limitation of this operative procedure. The patients in this series were divided into three groups according to postoperative intracranial pressure (ICP). Decompressive hemicraniectomy was effective in lowering ICP in all patients except for the cases that developed acute brain swelling. Overall mortality rate was 66.7% in this series. Preoperative clinical status, and intra- and postoperative ICP and CT findings obtained within 24 hours of operation were correlated with the operative outcome.

Intracranial haemodynamics in diffuse and focal brain injuries. Evaluation with transcranial Doppler (TCD) ultrasound

SummaryIntracranial haemodynamics were studied in 20 patients with diffuse and focal brain injury and experimental animals with acute intracranial hypertension by the use of TCD ultrasound. The mean flow velocity in the middle cerebral artery (MCA) commonly decreased on the side of the haematoma depending on intracranial pressure (ICP) elevation and cerebral perfusion pressure (CPP) reduction in focal injury. The decrease of the MCA flow velocity returned to normal after treatment. The flow velocities decreased bilaterally and there was no difference between the right and left side in diffuse injury. But the velocities increased in spite of ICP elevation when diffuse cerebral swelling developed. Cerebrovascular CO2 reactivity was impaired in two groups of patients with low Glasgow Coma Scale (GCS) scores. The mean velocity of the MCA and blood flow in the internal carotid artery exhibited flow patterns which changed correlatively depending on CPP reduction in experimental animals. Noninvasive study by use of TCD ultrasound can provide valuable information on variant haemodynamic phenomena in patients with diffuse and focal brain injury.

Monitoring of Severe Head-Injured Patients with Transcranial Doppler (TCD) Ultrasonography

Intracranial haemodynamics were studied in 36 patients with severe head injury and experimental animals with acute intracranial hypertension by the use of TCD ultrasound. The mean flow velocity (FV) in the basal cerebral arteries commonly decreased on the side of the haematoma depending on intracranial pressure (ICP) elevation and cerebral perfusion pressure (CPP) reduction in focal brain injury. The FV decreased bilaterally and there was no difference between the right and left sides in diffuse brain injury without a clear relationship between the FV and CPP. The FV of the middle cerebral artery and blood flow in the internal carotid artery exhibited flow patterns which changed correlatively depending on CPP reduction in experimental animals. Monitoring with TCD ultrasound is valuable in evaluating compression ischaemia in focal brain injury. But many complicated factors are considerable in diffuse brain injury.

Noninvasive study of critical thresholds of Intracranial pressure and cerebral perfusion pressure for cerebral circulation and brain function

To ascertain the critical thresholds of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) for cerebral circulation and brain function, the extra- and intracranial haemodynamics and electrical brain responses were evaluated noninvasively with Doppler ultrasonography and multimodality evoked potentials (MEPs) in 50 patients with severe head injury. Both extra- and intracranial blood flow velocities changed monotonically depending on the changes in ICP and CPP. They were decreased when ICP increased to 20-30 mmHg and when CPP decreased to 40-50 mmHg. The changes in elasticity index of the pulse wave of the common carotid artery was proportional to those of blood flow velocities. The frequency and degree of abnormalities of MEPs were proportionally increased with the rise of ICP and reduction of CPP. When ICP increased to higher than 31 mmHg, MEPs were classified as moderately or severely abnormal in more than 76% of the recordings. These results indicate that noninvasive study by use of Doppler ultrasonography and MEPs can provide valuable information on critical brain ischaemia and brain dysfunction in patients with acute intracranial hypertension.

Treatment of acute subdural hematoma with a low GCS score

In order to clarify the present problems in the treatment of acute subdural hematoma with low GCS score (5 or less), we studied the difference of the outcomes from two different surgical treatments for these patients. The present series included 30 patients who had GCS scores of 3, 4 or 5, and they were divided into two groups: 16 in DH group who had decompressive hemicraniectomy and 14 in HITT group who had hematoma irrigation with trephination therapy. The mean age of the patients was 47 years. They all had an intensive medical management including barbiturate therapy under intracranial pressure (ICP) monitoring after the operation. Time course of ICP after operation was classified as controlled, high but reduced and uncontrollable, based on the ICP level of 30 mmHg. The outcomes of the patients were determined by use of Glasgow outcome scale and classified into good, poor and dead. In these patients, the outcome was good in 13.3%, poor in 23.3% and dead in 63.4%. There was no survived case in those with GCS score of 3. The mortality rate in older patients over 60 years was high as 81.8%. ICP was well controlled in 2 patients (12.4%) in DH group. But there is no such case in HITT group. Uncontrollable ICP was more frequently seen in HITT group than in DH group. The patients showed different outcomes in the two types of treatment. Good outcome was found in 18.7% and the mortality rate was 56.3% in DH group. On the other hand, only one patient (7.1%) showed good outcome and the mortality rate of 71.4% in HITT group.(ABSTRACT TRUNCATED AT 250 WORDS)

Massive traumatic haematoma of the Corpus callosum

SummaryFive unusual cases with massive haematoma of the corpus callosum caused by blunt head trauma are presented. Aside from the callosal haematomas, intraventricular and subarachnoid haemorrhages or small haemorrhagic foci in the basal ganglia or thalamus were common concomitant lesions on the computerized tomographic (CT) scan. The sites of the impacts were the frontal and occipital areas which were close to the midline and above the level of the corpus callosum. Severe and diffuse brain dysfunction was suggested by the severity of the Glasgow coma score (GCS) and the abnormality on multimodality evoked potentials. An intensive medical treatment such as barbiturate could be promising since a direct surgical approach was dubious because of additional damage to the severely injured brain.

Neurovascular Decompression for Trigeminal Neuralgia associated with Hemifacial Spasm

A case of trigeminal neuralgia (TGN) associated with hemifacial spasm (HFS) caused by a tortuous vertebro-basilar (V-B) artery is reported. Computed tomographic (CT) scan with contrast enhancement (CE) was significantly useful in the diagnosis of the tortuous V-B artery. A 72-yearold man, complaining of intermittent facial pain and twitching of the left facial muscles, had been unsuccessfully treated with carbamazepine and nerve block. On admission, muscle twitch was seen in the left orbicularis oculi, cheek, and platysma muscles. Sensory disturbance was noted in the territory of the left trigeminal nerve. Corneal reflex was decreased in the left side. CT with CE revealed a linear structure in the prepontine cistern, suggesting a tortuous V-B artery. Left vertebral angiogram showed a markedly enlarged and tortuous V-B artery, protruding into the left cerebellopontine cistern. It was suggested that the tortuous V-B artery was the cause of both symptoms of TGN and HFS. Neurovascular decompression was then successfully performed. Immediately after the operation, the facial pain and the twitch completely disappeared. Eleven such cases have been reported in the literature, but this is the first report of a successfully treated case by neurovascular decompression.

A case of holoprosencephaly: with possible association of Dandy-Walker cyst.

The authors described a case of alobar holoprosencephaly with a huge cyst in the posterior fossa, possible representing a Dandy-Walker cyst, and marked cerebellar agenesis in the absence of median facial dysmorphias that has recently been encountered at our clinic.