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Purpose Infantile acute subdural hematoma (IASDH) has a limited age distribution and mostly benign clinical features. Mild-type IASDH has a stereotypical clinical course which, however, has been described in only a few studies.Methods Four male infants (aged 6–10 months; mean age: 7.5 months) were diagnosed as mild-type IASDH associated with retinal hemorrhage (RH) after suffering from occipital impact in a fall. The present case series reviews their clinical features and neuroimaging findings, including CT and MRI findings.Results All the infants fell backwards from a standing or sitting position onto a soft surface, striking the occipital region. They began crying on impact, then soon afterwards exhibited seizure-like activity or recurrent vomiting. CT and MRI revealed a thin, unclotted subdural hematoma (SDH) without mass effect or brain parenchymal abnormality. Various degrees of bilateral retinal hemorrhage (RH) were observed. On the day of symptom onset, all infants returned to baseline, and follow-up more than 5 years revealed normal development with no deficits.Conclusions Mild-type IASDH with retinal hemorrhage presents with seizure-like activity or recurrent vomiting preceded by crying after an occipital impact on a soft surface. The clinical course of IASDH is followed by rapid recovery on the day of symptom onset. CT and MRI findings reveal a small, unclotted subdural hematoma (SDH) without a mass effect or cerebral parenchymal abnormality.

Purpose Infantile acute subdural hematoma (IASDH) has a limited age distribution and mostly benign clinical features. Mild-type IASDH has a stereotypical clinical course that, however, has been described in only a few studies. Methods Four male infants (aged 6–10 months; mean age: 7.5 months) were diagnosed with mild-type IASDH associated with retinal hemorrhage (RH) after suffering from occipital impact in a fall. The present case series reviews their clinical features and neuroimaging findings, including CT and MRI findings. Results All infants fell backwards from a standing or sitting position onto a soft surface, striking the occipital region. They began crying on impact and then soon afterwards exhibited seizure-like activity or recurrent vomiting. CT and MRI revealed a thin, unclotted subdural hematoma (SDH) without mass effect or brain parenchymal abnormality. Various degrees of bilateral retinal hemorrhage (RH) were observed. On the day of symptom onset, all infants returned to baseline, and follow-up for more than 5 years revealed normal development with no deficits. Conclusions Mild-type IASDH with retinal hemorrhage presents with seizure-like activity or recurrent vomiting preceded by crying after an occipital impact on a soft surface. The clinical course of IASDH is followed by rapid recovery on the day of symptom onset. CT and MRI findings reveal a small, unclotted subdural hematoma (SDH) without a mass effect or cerebral parenchymal abnormality.

An acute subdural hematoma (ASDH) in infants without external signs of trauma is differently recognized as shaken baby syndrome (SBS) or abusive head trauma (AHT) in the United States or as infantile acute subdural hematoma (i-ASDH) due to minor head trauma in Japan. The aim of the present case report is to document the existence of i-ASDH as a discrete clinical entity differing from SBS and AHT.

A 13-year-old boy with medically intractable sinusitis-related intracranial epidural abscess in the frontal region was treated using percutaneous tapping. Drainage of pus measuring 7 ml yielded excellent postoperative course without cosmetic disadvantage on the forehead. Percutaneous tapping is considered to be the ideal treatment because of minimal invasiveness and cosmetic aspects of the wound.

71歳，男性．平成6年6月に直腸癌のため腹会陰式直腸切断術を受けている．術後再発徴候は無く，定期検診を続けていた．平成17年7月頃より人工肛門部からの出血が度々認められ，平成18年4月には，同部位に顆粒状の粘膜異常を伴う1.5cm大の粘膜下腫瘤を認めるようになったため，平成18年5月に腫瘍摘出術を施行した．病理組織学的診断では粘膜下に高度の炎症細胞浸潤を認め，結節状の腫瘤を形成していた．腫瘍性変化は認めず，炎症性偽腫瘍と診断した．直腸癌術後から隔日で洗腸を続けていたことが，炎症性偽腫瘍の原因になったと推察された．大腸原発の炎症性偽腫瘍では稀であり，人工肛門部での発症例はこれまでに報告がない．

特発性大腸穿孔は明らかな原因を認めずに大腸に穿孔をきたす比較的まれな疾患で, 予後不良といわれている. 今回, 82歳と84歳で2度にわたり特発性大腸穿孔を発症し, 救命しえた症例を経験したので報告する. 症例は84歳の女性で, 82歳時に特発性大腸穿孔にてHartmann手術を施行されている. 腹痛を主訴に近医より汎発性腹膜炎の診断にて当院に搬送された. 入院時78/48mmHgと血圧の低下を認めた. 腹部単純X線, CT検査にて腹腔内遊離ガス像を認め, 消化管穿孔の診断にて緊急手術となった. 人工肛門の口側8cmの部位に長径3cmの穿孔を認めたため, 穿孔部を含めて結腸を切除し, 新たに人工肛門を増設した. 病理組織検査より特発性大腸穿孔と診断した. 術後43日目に軽快退院した. 高齢者の突然の腹痛では, 本症を念頭において, 早期診断と適切な早期治療を心がけることが重要である.

The incidence of hemangioma is the highest of all benign tumors of the liver, but subjective symptoms are few and surgical tretment is performed only in symptomatic cases of giant tumor. We experienced two interesting patients with giant cavernous hemangioma of the liver showing subjective symptoms. Case 1 was a 45-year-old woman complaining of general fatigue and an abdominal mass. A giant hemangioma in the lateral and posterior segments of the liver associated with coagulopathy (reduced platelet counts and fibrinogen, and elevated total serum FDP) was diagnosed and hepatectomy was performed. Case 2 was a 34-year-old woman diagnosed as to have a giant hemangioma in the posterior segment of the liver. After a 7-year observation period the tumor suddenly start to enlarge, and subsequently a right upper abdominal pain and slight fever developed. Hepatectomy was performed in order to avoid the risk of rupture. Good results were obtained in both cases with disappearance of subjective and objective symptoms.

In order to investigate the duodenal motor activity after subtotal gastrectomy (Billroth-I, R2 lymph node dissection) for gastric cancer, migrating motor complex (MMC) of the duodenum was recorded using a micro-tip force transducer in 19 patients. At the same time serum levels of gastrointestinal hormone were measured. The following results were obtained. 1) MMC were observed in 12 patients, but not in the other 7 patients in whom only phase II was sustained. 2) It was suggested that the vagus nerve might not contribute to occurrence of MMC. 3) Possible participation of motilin and somatostatin as well as the necessity of their cooperation action in occurrence of MMC were also indicated.

Obturator foramen hernia is a relatively rare disease and is likely to occur in aged, thin females. Herein we report a case of obturator foramen hernia associated by incarcerated femoral hernia. A 95-year-old woman was seen at the hospital because of nausea and vomiting. At admission, she was diagnosed with incarcerated femoral hernia due to swelling at the right lower area of the groin. Because an abdominal simple X ray demonstrated intestinal obstruction as well as Howship-Romberg sign was obtained, a pelvic CT was performed. The pelvic CT demonstrated right obturator hernia. At laparotomy, a large omentum was incarcerated at the right femoral ring while the small intestine 130cm proximal from the terminalileum showed Richter type hernia at the right obturator foramen. Operative procedures included: reposition of the large omentum and the ileum; resection of a part of the large omentum; and closure of the hilus of the hernia. With a recent progression in imaging procedures, clinical cases diagnosed as obturator foramen hernia preoperatively have been increasing. Aggrssive examination sincluding CT scan are useful in making preoperative diagnosis of the disease, especially not to overlook associated hernia which is difficult to be detected by palpation like in this case.

We describe two patients with rebleeding from intracranial vertebral artery dissecting aneurysms during the acute stage. One patient had excellent results after emergency surgery. A review of recent reports including 60 patients with this disorder revealed a rebleeding rate of 30%, mostly during the acute stage. This suggests that a ruptured dissecting aneurysm in the vertebral artery is at risk for rebleeding during the acute stage, similar to a saccular aneurysm in the same location.

A 70-year-old male presented with rapid neurological deterioration and fever 3 months after suffering a closed head trauma. He underwent craniotomy for possible subdural empyema based on computed tomography and clinical findings. Dural incision revealed an outer membrane typical of chronic subdural hematoma which covered a clear, yellowish fluid containing Campylobacter fetus. Histological examination confirmed the capsule of the hematoma, with a necrotic focus infiltrated by neutrophils. Administration of intravenous imipenem and topical tobramycin and cefalothin achieved total resolution of his neurological deficits. Development of the infected subdural effusion was probably secondary to bacterial infection in the pre-existing chronic subdural hematoma in the resolving stage. The presence of the hematoma capsule always carries the risk of development of an infectious focus.

A 57-year-old male developed subdural effusion after head trauma, which remained asymptomatic and unchanged in volume during a follow-up period of 3 months. A typical chronic subdural hematoma (CSDH) developed 6 weeks after burr-hole exploration in spite of the absence of hematoma capsule or blood components in the effusion. The CSDH was successfully treated by irrigation and drainage. This case suggests that the presence of blood in subdural effusion may be the trigger for evolution of CSDH. We recommend that asymptomatic subdural effusion should be followed up without surgical intervention.

A 65-year-old male with a giant aneurysm of the vertebral artery, which had caused minimal neurological deficits for a few years, suffered rapid onset of respiratory disturbance followed by coma. Serial neuroimaging studies showed the thrombosed aneurysm continued to enlarge, resulting in increasing compression of the brainstem. Intraoperative observation and histological examination revealed that the aneurysm was composed of totally organized thrombus. Total extirpation of the giant aneurysm resulted in the patient regaining spontaneous respiration and clear consciousness, suggesting that growth of this aneurysm is due to increases in the size and number of the intrathrombotic capillary channels.

A 56-year-old female presented with chronic subdural hematoma due to spontaneous (primary) intracranial hypotension (SIH). She was admitted in a deep coma. Computed tomography showed bilateral chronic subdural hematomas with tight basal cisterns. Percutaneous aspiration of the chronic subdural hematoma with the twist drill revealed negative pressure. The neurological symptoms rapidly improved postoperatively, but the chronic subdural hematoma recurred three times, requiring further aspiration procedures. Patients with SIH may develop subdural hematoma requiring surgical treatment.

A 39-year-old male presented with a ruptured vertebral artery aneurysm at the level of the cervicomedullary junction. Neuroradiological imaging demonstrated the aneurysm but not the anatomical relationships. Surgery in the chronic stage revealed that the aneurysm arose from the lowest part of the intradural vertebral artery. No vertebral artery proximal to the aneurysmal neck was identified in the intradural space. Clipping was difficult through the intradural approach. Acute treatment of such aneurysms requires control of the extradural vertebral artery with temporary clipping.

Leiomyosarcoma of the stomach is a rare disease, and it's main metastatic forms are blood-borne metastasis and peritoneal dissem ination. Thus, the most common metastatic sites are the liver and peritoneum. However, resection of the liver for metastasis of this disease has rarely been reported. We present a patient with leiomyosarcoma of the stomach with liver metastasis who underwent total gastrectomy and liver resection twice for the metastasis. The patient was a 59-year-old woman who was admitted to a hospital associated with out university with gastric leiomyosarcoma and in whom liver metastasis was found in the lateral segment during total gastrectomy. She was readmitted to our clinic and underwent resection of the left lobe of the liver. Subsequently, she again developed a liver metastasis in S8 at 18 months after the resection of the liver and underwent a resection of that segment. Liver metastasis is considered to be an end-stage of cancer and has not been treated positively. However, the case presented here suggests that resection is the most effective treatment for liver metastasis of leiomyosarcoma of the stomach.

結腸憩室症の病変部結腸における蠕動反射,peptidergic nerveの調節について,大腸癌の正常部結腸を対照として,mechanogramおよび吸引電極法を用いて研究を行い,以下の結果を得た.(1)正常部結腸では,バルーン刺激によって口側に脱分極傾向とspikeを伴う収縮反応,肛側に過分極傾向を伴う弛緩反応という局所蠕動反射がみられ,その反射にはnon-cholinergic excitory nerve,non-adrenergic inhibitory nerveが関与していると思われ,substanceP(SP)neurotensin(NT)による脱分極傾向とspikeを伴う収縮反応すなわちnon-cholinergic excitory nerveの調節および,vasoactive intestinnal polypeptide(VIP)による過分極傾向を伴う弛緩反応すなわちnon・adrenergicinhibitorynerveの調節が認められた.(2)憩室症結腸では,バルーン刺激によって口側,肛側ともに脱分極傾向とspikeを伴う収縮反応が見られ,その反応はtetrodotoxin(TTX)投与下でも存在し,non-adrenergic inhibitory nerveの調節の低下および,筋層自体の異常興奮性が関与していると思われ,さらに,SP,NTの調節は正常部結腸と明らかな差は認めなかったが,VIPの調節が低下していると思われた.

Infantile acute subdural hematoma is clinically characterized by generalized convulsions, preretinal hemorrhage and bulging fontanelles occurring shortly after mild head injury mostly in infancy and in early childhood. In its mild form, the patient stays awake, though more or less irritable for several days, and mostly passes undiagnosed unless subdural tapping is performed. In its severer form, the patient lapses into a stuporous or comatose state with hemiplegia and/or other grave signs and sometimes dies. It is said that the majority of infantile chronic subdural hematomas originates from infantile acute subdural hematomas, although there are few documented cases reported as such. Four cases of infantile chronic subdural hematomas with a precedent history of infantile acute subdural hematomas were presented. Case 1 was a 14 month-old boy with CT and surgical evidence of bilateral chronic subdural hematoma. At the age of 9 months he had had a history of mild head injury followed by an immediate convulsion and a bulging fontanelle. Case 2 was a 15 month-old boy with the left hemiplegia and CT evidence of the right chronic subdural hematoma and of the right calcarine infarction. At the age of twelve months, he had had a mild occipital head injury followed by an immediate convulsion and disturbed consciousness. Case 3 was a seven month-old boy with CT evidence of bilateral subdural hematoma which was evacuated surgically. Three weeks prior to this, he fell down followed by an immediate convulsion and preretinal hemorrhage. CT taken two hours posttrauma documented the presence of an acute bilateral subdural hematoma. Case 4 was a twelve month-old girl with CT evidence of a left chronic subdural hematoma biconvex in shape. At the age of eight months, she had had a mild head injury followed by vomiting and a generalized convulsion. CT examination at that time was reported to show a thin acute subdural hematoma. This, however, had been considered thin enough to be treated conservatively. CT taken one month and two months, respectively, after the trauma showed widened low density areas over both hemispheres as well as prominent sulci and enlarged ventricles. These were mis-interpreted to indicate “brain atrophy”. The four cases of infantile chronic subdural hematomas reported here all had clinical evidence strongly suggestive of the presence of the preceeding acute subdural hematoma. One of them, moreover, had CT documentation of its presence. It may be concluded that infantile acute subdural hematoma, if untreated or neglected, is an important etiology of infantile chronic subdural hematoma.

A case of acute emphysematous cholecystitis is reported in which abdominal CT examination was useful for differential diagnosis.A 49-year-old man with no eventful history was ademitted to the hospital because of epigastric pain. A plain film image showed an abnormal gas shadow within the wall of the gallbladder. Abdominal CT examination confirmed the air-fluid level in the lumen of the gallbladder. These findings suggested acute emphysematous cholecystitis. Cholecystectomy was immediately performed. The distended gallbladder showed gangrenous cholecysitis, and the cystic duct was found to be obstructed by a small calcium bilirubinate stone at operation. Culture of the intraoperative gallbladder bile was positive and Bacteroides spp. was found. Pathological examination of the resected gallbladder showed gangrenous cholecystitis and emphysema of the mucosa. By progressive diagnostic imaging of the abdomen, we were able to make an early diagnosis of this disease. This was valuable since early operation is the best choice of treatment.

CT scans of 26 cases of subdural hematomas were carefully reviewed with particular emphasis on their densities. All the five cases of verified infantile chronic subdural hematoma, and four out of 15 cases of adult chronic subdural hematomas showed accumulations of CSF-dense fluid over the hemispheres, as well as in the cerebral sulci and cisterns, which were clearly demarcated from the overlying, rather highdense, subdural hematomas. The accumulation over the hemisphere was thicker where the underlying brain was severely atrophied. One of these had been erroneously diagnosed as ‘brain atrophy’. This and one adult case later progressed to a lentiform chronic subdural hematoma without CSF accumulation. Among six acute infantile subdural hematoma cases, three clinically mild cases showed accumulation of fluid in the sulci, fissures, and over the hemispheres, which gave the appearance of ‘brain atrophy’. Among three cases of severe form acute subdural hematomas, one showed a localized accumulation of CSF-dense fluid underneath the clot and over the hemisphere with sulcal patterns. In two cases of adult subdural effusions, metrizamide CT cisternography was performed. In both cases the dye not only filled the widely open cisterns and sulci, but also showed the existence of the subarachnoid space over the hemispheres and even beneath the subdural fluid space. From these observations it seemed logical that the subdural effusion (hematoma) was usually accompanied by enlargement of the subarachnoid spaces. In the acute phase, either primary subarachnoid hemorrhage or secondary bleeding from permeation of the subdural blood would cause blockage of the arachnoid villi, and the subsequent evolution of communicating hydrocephalus. In the chronic phase, however, hydrocephalus ex vacuo should play an important role, since the CSF accumulation appeared to have increased under decreased intracranial pressure with brain atrophy and/or enlargement of the calvarium, i.e., craniocerebral disproportion. Previous reports such as benign subdural collection of fluid, should be interpreted as the combination of subdural fluid with enlargement of the subarachnoid spaces. Similarly, in case termed benign enlargement of the subarachnoid spaces, benign communicating hydrocephalus, etc., the coexistence of subdural fluid must be considered and sought.

A 22-year-old female with compensated hydrocephalus suffered head trauma and developed an intracerebral hematoma with ventricular rupture and subsequent decompensation of the hydrocephalic process. Her consciousness progressively deteriorated, and ventricular drainage was performed to normalize her extremely high intracranial pressure. This case provides important information concerning traumatic brain damage in patients with hydrocephalus.

A 54-year-old, previously healthy female with chronic meningocencephalitis is presented. Computed tomography (CT) revealed hydrocephalus and mass lesions in both the lateral and fourth ventricles. A culture of cerebrospinal fluid obtained from the lateral ventricle on admission was negative, but 2 years later, when the meningoencephalitis recurred, Cryptococcus neoformans was cultured. The diagnostic difficulties and CT features of intracranial cryptococcal granulomas are discussed.

It is known that patients with craniocerebral disproportion are apt to suffer from acute subdural hematoma even after minor head trauma. Although the most common source of bleeding in subdural hematoma has been believed to be a ruptured bridging vein, reports of an arterial origin have recently increased.

When trauma occurs secondarily to a generalized seizure in patients with intractable epilepsy, even a simple subdural hematoma may be fatal if there is a delay in diagnosis. We encountered two such patients, both of whom suffered an acute, fatal subdural hematoma without cerebral contusion (simple subdural hematoma) as a result of falling during a generalized convulsion. In some cases, ophthalmoscopic examination is critically important in the early detection of simple subdural hematoma.

A rare neurosurgical event is described, in which an acute subdural hematoma developed during tack-up suture of the dura mater after evacuation of an acute epidural hematoma. The source of the second hematoma was determined to have been a ruptured bridging vein. The author discusses the potential risk of tack-up suture when there is a large gap between the dura mater and the inner surface of the skull.