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We herein report 2 cases of gastric cancer treated by S-1 and oxaliplatin combination therapy before later undergoing gastrectomy. The pathological results of both cases demonstrated complete response. Case 1 had a giant tumor which was suspected to have invaded the pancreas. Case 2 was associated with extensive lymph node metastasis. Based on the findings of these 2 cases, preoperative chemotherapy with S-1 and oxaliplatin for advanced gastric cancer shows sufficient efficacy.

We report a case of resection of a paraaortic lymph node recurrence, wherein complete response to bevacizumab was observed. Our patient was a 50-year-old woman who had a paraaortic lymph node recurrence during adjuvant chemotherapy with FOLFOX 6 months after surgery for sigmoid colon cancer. She was treated with chemotherapy consisting of FOLFOX plus bevacizumab/FOLFIRI plus bevacizumab, which suppressed progression of the periaortic lymph node recurrence. She underwent surgery for the paraaortic lymph node recurrence, and the pathologic result was complete response. We report that bevacizumab was effective for her paraaortic lymph node recurrence.

We reviewed 21 patients with locally advanced breast cancer with distant metastasis.The median age was 61 years.The median time to presentation at hospital was 13 months, and the median neoplasm diameter on the first visit was 10 cm.The main histological type was scirrhous carcinoma.Sixteen cases tested positive for hormone receptor(76%), 4 tested positive for HER2(19%), and 3 were triple negative(14%).Four patients underwent surgery.The techniques performed included mastectomy and axillary lymph node dissection.Three patients experienced local recurrence.The first-line treatment was surgery for 1 patient, chemotherapy for 12 patients, hormonal therapy for 7 patients, and trastuzumab for the HER2 positive patients.The median follow-up period was 49 months.The patients for where an operation was performed were 49 months and the operation not- enforcement patients were 54 months.If treatment is possible for patients with locally advanced breast cancer with distant metastasis, multidisciplinary treatment according to individual patient characteristics is recommended. In the case of surgical treatment, careful consideration must also be given to these characteristics.

A 61-year-old man was diagnosed with rectal cancer with multiple liver metastases in December 2009, and low anterior resection of the rectum was performed. Postoperative adjuvant chemotherapy with 6 courses of oxaliplatin, Leucovorin, and 5-FU (FOLFOX4) and bevacizumab was initiated, followed by 5 courses of fluorouracil, Leucovorin, and irinotecan (FOLFIRI) and bevacizumab. Right posterior segment (S6, S7) hepatectomy with enucleation of S2, S3 and S5 was performed, and chemotherapy with FOLFOX4 (11 courses) was administered. New metastases in the S5 segment were observed in August 2011 and right hepatic lobectomy was performed. The patient then underwent 8 courses of adjuvant chemotherapy with FOLFOX4. However, left hepatic lobe lateral segment and caudate lobe metastases then appeared. Subsequent repeated chemotherapy with FOLFIRI plus cetuximab (3 courses) and irinotecan plus cetuximab was interrupted in August 2013 owing to adverse events resulting in rapid growth of hepatic metastases. The patient underwent hepatic left lateral segmentectomy and left caudate lobectomy. The postoperative course was uneventful and the patient has currently survived 4 years and 7 months after the initial surgery.

We report a case of gastric cancer accompanied by disseminated carcinomatosis of the bone marrow treated with S-1 and cisplatin( CDDP) combination chemotherapy. The patient was a 68-year-old woman who was detected as having disseminated intravascular coagulation( DIC) during an examination for gastric cancer and she was diagnosed as having disseminated carcinomatosis of the bone marrow by lumbar puncture. She was immediately treated with S-1 and CDDP combination chemotherapy( S-1, 80 mg/body orally administered[ po] on days 1-21 and CDDP, 60 mg/body intravenously [iv] administered on day 8) and her DIC improved on the fourth day. Subsequently, the patient was treated with 3 courses of combination chemotherapy and she survived for 184 days from the initiation of the treatment. Although disseminated carcinomatosis of the bone marrow is associated with a poor prognosis, we believe that the duration of survival of our patient was extended due to initiation of chemotherapy at an early stage.

To elucidate the mechanism of excessive size of the head in Sotos syndrome, serial neuroimaging features from birth were reviewed in two patients. Macrocephaly shortly after birth was attributed to increased volume of the cerebral parenchyma itself (megalencephaIon). Subsequent excessive size of the head was related to retention of cerebrospinal fluid in the ventricles and the subarachnoid spaces. Thus, macrocephaly in Sotos syndrome reflects two different mechanisms. The value of serial evaluation of intracranial structures is emphasized. [Neural Res 1998; 20: 149–152]

A 55-year-old man with traumatic acute subdural hematoma (SDH) was managed nonsurgically because of having isolated mild headache that resolved within a week. However, the patient developed an acute onset of amnestic aphasia 12 days post-trauma. Although the SDH itself did not increase in volume, remarkable swelling of the ipsilateral cerebral hemisphere was observed on CT scanning. Craniotomy was required since the main component of the SDH was solid and partially organized. Post-operative recovery from his speech disturbance was delayed, necessitating speech therapy for more than two months. Additionally, decreased cerebral blood flow on the affected side was observed even 3 months after injury. Symptomatic subacute SDH exclusively presenting as focal neurological deficits, though very rare,is worthwhile to be kept in mind as a pitfall in nonsurgical management of acute SDH.

Case report: An 8-year-old boy who was treated for hydrocephalus with lumboperitoneal shunting presented with extreme night bradycardia. Results and conclusion: The night bradycardia disappeared after shunt revision, suggesting that the probable cause was secondary to long-lasting increased intracranial pressure (ICP). Long-lasting increased ICP is known to be associated with papilledema, but it has rarely been reported to induce night bradycardia in clinical practice. Extreme night bradycardia in this setting is not only a clinical sign of increased ICP but also a possible cause of cardiogenic sudden death, which must be borne in mind in the management of patients with shunted hydrocephalus.

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.

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.

✓ The cases of 30 infants with chronic subdural hematoma treated surgically between 1978 and 1987 (after the introduction of computerized tomography) were reviewed. This series was limited to infants presenting with increased intracranial pressure, neurological deficits, or developmental retardation. Nineteen patients were male and 11 were female, ranging in age from 1 to 14 months (average 6.1 months). The surgical treatment was initiated with percutaneous subdural tapping which was repeated periodically, if indicated, for 2 weeks. If the patients failed to respond to subdural tapping, subdural-peritoneal shunting was installed. The follow-up periods were from 3 months to 9 years 8 months (average 4 years 10 months). Computerized tomography at that time disclosed disappearance or minimal collection of subdural fluid in 28 cases (93%) and a significant collection (> 5 mm) in two (7%). Neurological examination revealed that the patients were “normal” in 17 cases (57%), “mildly or moderately disabled” in nine (30%), and “severely disabled” in four (13%). The majority of disabled patients had lesions secondary to infantile acute subdural hematoma, child abuse, or hemorrhagic diathesis. These results indicate that the treatment protocol in the present series is acceptable for the elimination of subdural hematoma. Together, early diagnosis and treatment of the etiological conditions causing the lesion are indispensable for obtaining a satisfactory neurological outcome.

Two cases of TS associated with brain tumors had severe psychomotor retardation and early onset of long-term intractable convulsions, compared with cases without tumors. In one case, the tumor was partially cystic and progressed rapidly. Immunohistochemical studies of neuron specific enolase, glial fibrillary acidic protein and myelin basic protein revealed differences in positivity between cell types and between cases. These results suggested that the origin of the tumor cells could be variably differentiated cells.

Embryonal urachus exists as a cord-like structure between the urinary bladder and the umbilicus. In some cases of urachal cysts at the level of the navel, no special symptoms are detected during childhood, but spontaneous drainage at the navel may occur after adolescence, which is called an infected urachal cyst. Especially in cases accompanied by infected omphalitis, no constant opinion has been established to choose either initially curative resection or staged incision. In this study, we evaluated the characteristics of patients with urachal cysts who underwent the staged approach. Twenty patients (14 men and 6 women) with urachal cysts complicated by infected omphalitis were treated in our hospital. Staged surgery was performed for 18 patients. Neither recurrent omphalitis nor subsequent urachal carcinoma was observed. It is desirable that urachal cyst accompanied by intractable omphalitis should be treated by conservative therapy, conducted image diagnosis, and chosen staged surgery.

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.

We report a 64-year-old woman who underwent mastectomy for stage II (T2N1M0) advanced breast cancer, in whom multiple spine metastases developed 18 months postoperatively. She received 6 cycles of CA (cyclophosphamide 500 mg/m2, ADM 50 mg/m2 3 wq) therapy and oral tamoxifen (20 mg/body) administration for adjuvant therapy. The multiple bone metastases of the spine were revealed by technetium bone scan. The level of serum tumor marker CA15-3 increased two times over the normal range 18 months after surgery. She also developed osteoporosis a few years later, so we selected high-dose toremifene administration (120 mg/body) as a second-line therapy. No adverse effects have occurred and bone metastases disappeared. Moreover, the tumor marker was also normalized 6 months after toremifene therapy started. It was shown that high-dose treatment of toremifene was useful for recurrent breast cancer with bone metastasis.

The patient was a 50-year-old female with peritoneal metastasis of Type 4 gastric cancer. She underwent a relative curative resection with total gastrectomy and peritonectomy. Postoperative chemotherapy with 5'-DFUR following 5-FU and CDDP was performed. Thirteen months after surgery, cancer recurrence was suspected due to elevated levels of the serum tumor markers carcinoembryonic antigen (8.9 ng/ml) and alpha fetoprotein (85.8 ng/ml). She was additionally treated with UFT 300 mg/day and Lentinan 2 mg/week. The serum tumor markers decreased gradually returned to normal levels. At 5 years and 8 months after surgery, she is alive without any sign of recurrence.

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.

Ulcerative colitis (UC) associated with Takayasu's disease (TD) is not common in Japan. Here, we report two patients with both diseases who received a total proctocolectomy. Patient 1, a 41-year-old woman with chronic continuous type UC, was first diagnosed with TD at the age of 10 years. Subsequently, she was diagnosed with UC and rectal cancer. HLA typing showed A2, A31(19), B52(5), and DR2(DRB1*1502). Coronary angiography showed 90% narrowing of the right coronary artery (RCA). After alleviating the RCA narrowing by percutaneous transluminal coronary angioplasty (PTCA), we performed a total proctocolectomy and ileostomy. Patient 2, a 20-year-old woman, was first diagnosed with TD at the age of 13 years. Severe symptoms, indicating fulminant UC, started 1 month prior to hospitalization. She was judged as needing surgery because the symptoms were not alleviated even with high doses of prednisolone. HLA typing showed A2, A31(19), B52, B61(40), DR2(DRB1*1502), and DR4 (DRB1*0405). Aortography showed a narrowing of the right renal artery; however, her renal function was normal. Based on these findings, we performed a three-stage operation for total proctocolectomy. Previously, we have reported that the DRB1*1502 and DRw11 genes were closely related to the intractability of UC. To date, we have not determined whether or how the DRB1*1502 gene might be related to TD. As the number of cases of UC associated with TD increases, it will be necessary to examine their DR2 subtypes.

In an effort to maximize the effectiveness of subdural-peritoneal shunting for the treatment of chronic subdural hematoma in infants, the author developed a new shunt system. The characteristics of this shunt include a large-caliber catheter, a very low pressure slit valve, and a one-piece design with a large flushing device. This shunt is particularly useful for patients without increased intracranial pressure, who are usually refractory to treatment using a conventional ventriculoperitoneal shunt system.

A patient who suffered rapid deterioration due to cerebral vasospasm 18 days after aneurysmal subarachnoid haemorrhage is reported. Unusually delayed onset of ischaemic neurological deficits and its preventative management is discussed.

An eight-month-old boy with clinical features of acute encephalopathy with symmetrical low-density areas in the thalami and the putamen on computed tomography is presented. These particular computed tomography features suggest potential aetiology common to acute encephalopathy with low-density areas in the thalami and infantile bilateral striatal necrosis with an acute onset The therapeutic consideration of these conditions is also discussed.

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.

A 57-year-old, previously healthy man who developed acute onset of hemiplegia is presented. Neuro-imaging studies on admission suggested dissection of the middle cerebral artery producing infarction in the frontotemporal region. In contrast to his stable clinical course, serial neuro-imaging studies disclosed rapid growth of malignant glioma, which was confirmed at surgery. Microscopic examination of the surgical specimen demonstrated invasion of glioma cells into the arterial wall associated with intramural haematoma formation of the middle cerebral artery. This case is the first to document dissection of an intracranial artery caused by invasion of tumour cells.

The authors report a case of postoperative middle meningeal arteriovenous fistula found after craniotomy for aneurysmal surgery using the pterional approach. It was no longer demonstrable at the follow-up examination 3 months later.

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 long-term follow-up study was conducted in 28 pediatric patients treated with lumboperitoneal shunting. Shunt malfunction was observed in 3 patients (10.6%) who presented with isolated ophthalmological abnormalities 3, 5, and 11 years after surgery. The mechanism of this phenomenon is con-sidered to be very slowly developing malfunction secondary to shortening of the spinal catheter associated with child's growth. The importance of periodic funduscopic examination in patients treated with lumboperitoneal shunting in infancy is stressed.

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 case of neonatal congenital triventricular hydrocephalus due to a small intracranial lipoma in the quadrigeminal plate cistern is reported. The patient was treated by a ventriculoperitoneal shunt. The mechanism of obstructive hydrocephalus caused by the intracranial lipoma is discussed.

✓ The pathological process of extracerebral fluid collections in infancy includes subdural effusion and enlargement of the subarachnoid spaces. Both conditions have traditionally been investigated as a single clinical entity, because of difficulty in differentiating between them. The prognosis of subdural effusion is not as benign as that of enlargement of subarachnoid spaces, requiring differential diagnosis between these disorders. The present study was conducted to elucidate whether this differentiation could be made on magnetic resonance (MR) images.The series consisted of 16 infants aged 10 months or younger, including eight with verified subdural effusion and eight in whom a diagnosis of enlargement of the subarachnoid spaces was achieved by neuroimaging studies other than MR imaging. In all eight patients with subdural effusion, the intensity of the fluid was greater than that of cerebrospinal fluid (CSF) in at least one of the sequences using T1-weighted, proton-density, and T2-weighted MR images. The flow-void sign, indicating vessels in the fluid spaces, was not seen in any of these eight patients. On the other hand, in all eight patients with enlargement of the subarachnoid spaces, the fluid was isointense in relation to CSF, and vascular flow-void areas were seen in at least one of the MR imaging sequences. Based on these observations, it is concluded that differentiation between subdural effusion and enlargement of the subarachnoid spaces can be established by focusing on two aspects of MR imaging findings: 1) the intensity of the fluid, which is either iso- or hyperintense relative to CSF, and 2) the presence or absence of vascular flow-void areas in the fluid spaces.

A case of acute subdural haematoma caused by ruptured arteriovenous malformation is reported. At surgery, there was no association with intracerebral haematoma or definite subarachnoid haemorrhage. The mechanism of acute subdural haematoma in the present case was considered to be rupture of an arteriolized bridging vein drained by arteriovenous malformation. [Neurol Res 1993; 15: 353-355]

The terminal phase of pontine glioma is reportedly characterized by disturbance of consciousness. The authors retrospectively reviewed 8 children who died of pontine gliomas in their hospitals. The hospital records were analyzed specifically in regard to neurological status and terminal case. All children became mute and quadriplegic with cranial nerve palsies. The oldest child, 17 years in age, unquestionably showed the classical locked-in syndrome for the last 4 months. Six of the remaining 7 (average 5 years of age), while labeled as semicomatose, responded to calling by blinking and/or vertical eyeball movement. The authors consider that they were indeed awake in the locked-in state until very near death. This would raise a serious ethical problem of whether or not they should be intubated and kept ventilator-dependent at the time of respiratory failure, which often occurs.

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.

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.

A 52-year-old male underwent lumboperitoneal shunting after external decompressive craniectomy. His postoperative course was accompanied by remarkable displacement of the intracranial structures to the opposite side of craniectomy. This phenomenon, probably caused by the siphon effect of cerebrospinal fluid shunting, resolved after cranioplasty. This observation- provides the evidence casting doubt on the presence of the siphon effect due to atmospheric pressure in patients without the association of skull defect or open cranial sutures.

✓ Postoperative venous infarction following aneurysm surgery was studied in 48 patients with anterior communicating artery aneurysms operated on through the interhemispheric approach at the acute stage of subarachnoid hemorrhage (SAH). Of 23 patients whose bridging veins were sacrificed during surgery, 11 (47.8%) showed venous infarction in the frontal lobes. In contrast, only one (5.9%) of 17 patients whose bridging veins were preserved developed cerebral edema. None of eight patients who were operated on after Day 11 (the day of SAH was defined as Day 0) showed this complication, although bridging veins were sacrificed in six of them. Venous infarction following acute aneurysm surgery tended to occur more frequently in patients of higher SAH grade and/or more advanced age, but these correlations were not significant. However, the correlation between the sacrifice of veins and venous infarction was significant (p < 0.025). Because this potential complication may compromise the benefit of acute aneurysm surgery and cause damage, it is important to preserve the venous system and in some instances to select another surgical approach based on the pattern of venous drainage in the frontal lobe.

This 1-year-old male infant had been diagnosed with cerebral degenerative disease because he developed psychomotor regression, and brain atrophy was demonstrated on computed tomography. He underwent magnetic resonance imaging, which suggested a cerebrovascular malformation. Cerebral angiography disclosed an arteriovenous fistula, fed by an anterior cerebral artery and directly draining into a cortical vein. The occlusion of the feeding artery was followed by a satisfactory recovery. The mechanism of the neurological symptoms in this patient is thought to be caused by a steal phenomenon and compression of the brain stem by venous engorgement in the posterior fossa.

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.

Serious complications following installation of a cyst-peritoneal shunt in an 8-year-old boy with asymptomatic arachnoid cyst in the middle cranial fossa are reported. Highly elevated intracranial pressure without association of ventriculomegaly seen in this patient indicates slit ventricle syndrome caused by malfunction of the cyst-peritoneal shunt. This phenomenon is worth recognizing as a possible consequence of cyst-peritoneal shunting for the treatment of intracranial arachnoid cyst.

A case of arachnoid cyst in the middle cranial fossa complicated by intraoperative subdural hemorrhage is presented. Accumulation of cerebrospinal fluid (CSF) outside the outer wall of the arachnoid cyst was found to induce the rupture of well-developed, fragile leptomeningeal vessels at the base of the middle cranial fossa. This phenomenon is noteworthy as a pitfall in surgery for intracranial arachnoid cyst and suggests the bleeding source of subdural hematoma occasionally associated with this lesion.

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.

A 21-YEAR-OLD WOMAN, who had undergone foramen magnum decompression for her symptomatic Chiari malformation (Type 1) 7 years before, presented with recurrence of the symptoms. Neuroradiological examinations demonstrated regeneration of the foramen magnum that was caused by new bone formation, as confirmed at the second surgery. Neurological improvement was obtained after the removal of the regenerated foramen magnum. This observation, though rare, deserves to be kept in mind during the postoperative follow-up period in young patients with Chiari malformation. (Neurosurgery 37 :340-342,1995)

Lumboperitoneal (LP) shunting has the advantage of completely extracranial surgical management, minimizing intracranial complications. An LP shunt has been intentionally adopted for patients who require cerebrospinal fluid diversion. A retrospective study was designed to examine the indications for and complications associated with LP shunts in 207 patients (including 28 pediatric patients) treated during the past 11 years. Follow-up averaging 5.1 years revealed no deaths related directly to LP shunt placement. Twenty-nine patients (14%) underwent revision of the shunt because of obstruction. Shunt-related infections were observed in only 2 patients (1%). Radicular pain occurred in 10 patients (5%), 2 of whom required shunt replacement. Postoperative occurrence of dyspnea and disturbance of consciousness necessitated conversion to a ventriculoperitoneal (VP) shunt in 2 patients (1%), who subsequently were noted to have Chiari malformations. In 4 patients (2%), an acute subdural hematoma developed after mild head trauma, Symptomatic chronic subdural hematomas were observed in 2 patients (1%). One patient had a mild myelopathy that rapidly resolved after shunt replacement. The comparison to 120 patients treated with a VP shunt during the identical period (an average follow-up of 5.2 years) suggests the following conclusions. After subarachnoid hemorrhage caused by a ruptured aneurysm, hydrocephalus is usually of the communicating type and is an indication for an LP shunt. The incidence of infection and malfunction with an LP shunt is significantly lower than that with a VP shunt. An LP shunt is also indicated for pediatric patients, although a relatively higher incidence of malfunction is noted compared to adults. In the light of their simplicity, extracranial management, and fewer complications, it is suggested that LP shunts be more widely used by neurosurgeons.

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.

With computed tomography, triventricular hydrocephalus shows enlargement of the 3rd and both lateral ventricles with a nearly normal size 4th ventricle. Triventricular hydrocephalus has been described as noncommunicating because of aqueductal stenosis or obstruction. The authors, however, have encountered three patients whose computed tomographic (CT) images were those of triventricular hydrocephalus despite a patent aqueduct. This condition may be suitably referred to as communicating triventricular hydrocephalus because in all cases metrizamide CT cisternography demonstrated the communication between the spinal subarachnoid space and both lateral ventricles. The authors discuss its treatment with a lumboperitoneal shunt.

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.

Chronic subdural haematoma in adults has been treated by percutaneous subdural tapping using a subdural needle. In order to prevent recurrence, the procedure including replacement of the haematoma with oxygen, irrigation using relatively small amounts of saline, and additional drainage for one hour proved to be simple and reliable. The detailed technique is illustrated, and sequential computed tomography scans in six patients treated with this procedure are presented.