Yasushi Kurokawa

The relationship of cloverleaf skull syndrome to hydrocephalus

In 1960, Holtermüller and Wiedemann described chondrodystrophic hydrocephalus as Kleeblattschädel syndrome. In the present paper, we review 23 cases of this syndrome associated with hydrocephalus, including 2 cases of our own. Of these 23 cases, 8 involved communicating hydrocephalus and 15 non-communicating hydrocephalus. It has been speculated that the associated hydrocephalus results from basilar impression, compression of infratentorial structures, aqueductal stenosis in non-communicating hydrocephalus, and impairment of venous drainage and cerebral spinal fluid flow at the level of the constrictive cranial ring in communicating hydrocephalus. Our present cases also showed this cranial ring, as demonstrated by skull X-rays and computed tomography scans. Since cloverleaf skull syndrome often has other general anomalies, we consider the hydrocephalus in this syndrome to have causes associated wtih the osteocartilaginous system.

Surgical strategy for cavernous angioma in hypothalamus

A very rare case of cavernous angioma in the hypothalamus is presented. The patient was successfully treated by total excision of the haematoma and angioma, and there was no regrowth of the lesion on follow-up MRI. Complete excision of the angioma is the recommended surgical strategy even for patients with deep-seated lesions.

Direct surgery for giant aneurysm exhibiting progressive enlargement after intraaneurysmal balloon embolization

A case of giant intracranial carotid artery aneurysm exhibiting progressive enlargement after incomplete intraaneurysmal balloon embolization is presented. The patient was successfully treated by the trapping and decompression of the aneurysm with a superficial temporal artery-middle cerebral artery anastomosis. The thrombus surrounding the intraluminal balloons was very soft and poorly organized. Either direct surgery with extracranial-intracranial arterial bypass or complete intravascular surgery should be performed for giant aneurysms when direct clipping is impossible.

Zygomatic Approach to Vascular Lesions in the Skull Base

Lesions located in the middle fossa, prepontine and interpeduncular cisterns are some of the most difficult to approach in case of radical surgery, even with the aid of an operating microscope. To minimize the retraction of the temporal lobe and achieve wide exposure, many operative modalities have been reported. We describe a zygomatic approach without removal of the lateral orbital rim, which we developed based on a modification of Fujitsus approach. This approach has been used in 8 patients: 2 with aneurysms in the territory of the basilar artery, 3 with brain stem ischemia, 1 with a hypothalamic hematoma, and 1 with a cavernous angioma in the midbrain. The last patient had an anterior communicating artery aneurysm and a concomitant temporal convexity meningioma. Complete clip ligation was performed for all 3 aneurysms and gross total removal was achieved in hypothalamic hematoma case and cavernous angioma case. Also, the anastomosis of the superficial temporal artery to superior cerebellar artery was performed for 3 patients with brain stem ischemia. One patient with a large basilar tip aneurysm died due to initial damage of the brain on attack. Another with cavernous angioma developed left hemiparesis and oculomotor palsy but these symptoms markedly improved 6 months after the operation. The complications we observed in this series, consisted of 2 types. The first comprised temporary third nerve paresis in 2 cases and the second was temporal muscle atrophy. Based on our experience and the operative results obtained, we concluded that this procedure allows a wide operative field and easy access to the interpeduncular fossa with minimal brain retraction.

Usefulness of the Initial Clipping on Surgery of the Cerebral Aneurysm

The prognosis of patients with subarachnoid hemorrhage due to a ruptured cerebral aneurysm is chiefly influenced by initial damage of the brain on insult, the operation and the occurrence of vasospasm. However, the operation may play the most important part of these three factors. The authors think that the results of an operation for cerebral aneurysms will depend on the occurrence of premature rupture during the dissection of an aneurysm from the surrounding tissue. In order to prevent premature rupture of a cerebral aneurysm and to shorten the time of temporary clipping of the parent arteries during dissection, the authors use the technique of initial clipping with good results. So, the authors explain the technique of initial clipping in our representative cases. Finally, based our experiences, the authors state the merits of this technique and discuss its usefulness in surgery.