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While the efficacy of cerebrovascular bypass surgery for Moyamoya disease with ischemic events has been substantiated, the surgical indication for the patients presenting with intracranial hemorrhage is as yet undetermined. In an effort to prevent rebleeding from rupture of Moyamoya vessels, seven patients with intracranial hemorrhage underwent indirect bypass surgery. During the follow-up period between 2 and 11 years (mean 4.9 years), one patient suffered rebleeding 5 years after bypass surgery. Follow-up cerebral angiography failed to show revascularization and reduction of moyamoya vessels in all but one of seven patients. Thus, the author's experience suggests that bypass surgery for Moyamoya disease with hemorrhage is angiographically far less successful compared to that with ischemia. A review of the series including patients with angiographically successful revascularization and reduction of Moyamoya vessels failed to demonstrate the definitive effectiveness in eliminating the risk of further intracranial hemorrhage.

A case is presented in which recurrence of acute subdural hematoma developed 29 days after head trauma. An emergency craniotomy was complicated by intraoperative profuse bleeding, which was caused by the rupture of a large false aneurysm of the middle meningeal artery. A pitfall in the surgical treatment of this rare lesion is discussed.

Preoperative evaluation using serial magnetic resonance imaging was performed on an infant with lumbosacral lipoma. Syrinx formation arising just above the lipoma was observed in conjunction with rapid growth of the lipoma. Definite shrinkage of syringomyelia was obtained after radical excision of the lipoma. The syrinx formation was possibly caused by compression from the extramedullary lipoma.

BACKGROUND This case illustrates that although percutaneous subdural tapping for patients with chronic subdural hematoma (CSDH) is successful and minimally invasive, it can be complicated by acute epidural hematoma. CASE PRESENTATION A 62-year-old woman presented with headache two months after minor head trauma. Computed tomography (CT) scanning revealed CSDH with mixed density on the right side. Prior to percutaneous subdural tapping, twist-drill craniostomy was performed at the parietal tuber. When the drill-needle reached the dura mater, the patient began to complain of headache, which was followed by altered consciousness. CT scanning disclosed acute epidural hematoma abutting the CSDH; both hematomas were evacuated by emergency craniotomy. At surgery, no definite bleeding source was identified apart from oozing on the dura mater. CONCLUSION Hemorrhagic complications after percutaneous subdural tapping are rare. The formation of acute epidural hematoma during twist-drill craniostomy has not been reported in the literature. This complication can occur when the blunt tip of the drill-needle remains on the dura mater without penetrating into the subdural hematoma cavity.

Seeking radical removal of chronic subdural hematoma using a simple and less invasive procedure, the author has devised a new method--replacement of the hematoma with oxygen via percutaneous subdural tapping. In this study, 40 patients were treated with this procedure. All patients made a full recovery after the treatment, without complications related to replacement of the hematoma with oxygen. Follow-up investigation showed recurrence of the lesion in two patients (5%). Because of its simplicity, reduced invasiveness, and short hospitalization, the procedure presented here is acceptable as an optimal therapeutic modality for chronic subdural hematoma in adults. Theoretical considerations supporting the safety of this procedure are discussed.

The remarkable growth of an intradural lipoma during a period of 6 months is demonstrated by serial magnetic resonance imaging in an infant with lipomyelomeningocele. This observation provides additional support for early prophylactic surgery in patients with lipomyelomeningoceles.

Over a 2-year period, 5 of 10 patients with revision of ventricular shunting were complicated by intraventricular and/or intracerebral hemorrhage due to avulsion of the choroid plexus. Retrospective analysis of computed tomography scans prior to the revision disclosed the presence of an intraventricular or periventricular mass adjoining the ventricular catheter in four of the five patients. Histologic findings of the soft tissue at the tip of the removed catheter were compatible with the choroid plexus accompanied by granulation tissue. The risk factors useful for detecting the possible occurrence of this complication are discussed.

A superficial scalp wound can be approximated by tying the hair on each edge of the wound, without shaving or using suture material. This technique is useful in selected patients with lacerated scalp wounds, and its technical details and indications are described.

Two cancer patients are reported, who presented with altered consciousness 2 and 3 months, respectively, after the administration of 5-fluorouracil derivatives, and progressed to a state of akinetic mutism. At first a presumptive diagnosis of metastatic brain tumor was made. However, the result of a cerebrospinal fluid cytology for malignancy was negative, and computed tomography (CT) scanning revealed diffuse decreased attenuation of the cerebral white matter, indicative of leukoencephalopathy, without association of mass lesion. Upon discontinuing the drugs, both patients made significant recovery and the decreased attenuation on the CT also disappeared. The significance of the early diagnosis of this pathology is emphasized.

The author analyzed the appearance on computed tomography after infusion of contrast medium of cerebellar infarction in three patients, whose diagnosis was made on the basis of clinical presentation, cerebral angiography, and sequential computed tomographic scans. Their computed tomographic appearance was not always the same as seen in the supratentorial counterpart, in showing reminiscence of an arteriovenous malformation, a leptomeningeal dissemination of a tumor or meningitis, or a neoplasm, respectively. For these reasons, it was concluded that it is important to notice the contrast-enhanced computed tomographic appearance in cerebellar infarction, when making a differential diagnosis between various pathologies in the posterior fossa.

The cases of four patients treated with a lumboperitoneal shunt in whom acute subdural hematoma occurred after minor head trauma are presented. Three of the four patients had subdural fluid collection or widening of subarachnoid space observed on computed tomography scan after placement of the lumboperitoneal shunt. We report that patients with a lumboperitoneal shunt have the potential to develop acute subdural hematoma due to minor head trauma, and discuss its mechanism.

A female infant is diagnosed as having Larsen's syndrome associated with hydrocephalus. Larsen's syndrome is a rare disease characterized by congenital multiple joint dislocations and unusual facies. The pathogenesis is described as a mesodermal disorder. The present case remains a medical curiosity because there have been no previous reports of Larsen's syndrome associated with anomalies of the central nervous system. The author discusses the etiology, linking Larsen's syndrome to the hydrocephalus seen in this patient.

Two nonhypertensive adult patients with asymptomatic occlusion of the middle cerebral artery, in whom caudate head hemorrhage occurred ipsilateral to the occlusive lesion, are described. The mechanism of this hemorrhage is surmised to be identical to that of moyamoya disease: a rupture of the dilated, fragile lenticulostriate artery, which evolved as a collateral channel in response to chronic cerebral ischemia.

Intracranial changes in two patients with unilateral coronal synostosis were evaluated by computed tomography (CT). Preoperative CT scans showed local compression of the brain by the flattened frontal bone with definite shift of the midline structures, suggesting that unilateral coronal synostosis may be harmful to the growing brain in infants. Postoperative restoration of the intracranial changes led me to draw the conclusion that unilateral coronal synostosis should be treated as early as possible not only for cosmetic reasons but also for the prevention of parenchymal damage.

A sudden onset of quadriplegia and dyspnea occurred in a 4-year-old girl with Down's syndrome, who had been noted to have atlantoaxial dislocation. She underwent cervical immobilization initially with a halo-vest and subsequently by posterior fusion, resulting in significant functional recovery. The catastrophic myelopathy that occurred in this patient emphasizes the necessity of treatment even for asymptomatic atlantoaxial instability in some individuals with Down's syndrome.

After administration of short-term high-dose prednisolone in two patients with brain tumors, avascular necrosis of the femoral head was noted 7 and 15 months later, respectively. Both patients required replacement of the femoral heads. Despite the extensive use of steroid therapy in neurosurgical practices, reports of avascular necrosis of bone have been exceedingly sparse. This pathological condition evolves several months later, and has received scant attention in the neurosurgical literature. Particularly in patients with hemiparesis, the hip joints on the affected side are thought to suffer from avascular necrosis more frequently. For this reason, sufficiently long-term observation for the early detection of this complication is necessary in patients treated with steroids.