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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 subchiasmal carotid-ophthalmic aneurysm was clipped through a combined contralateral pterional and interhemispheric approach. This combined approach seems very useful for some particular aneurysms of this portion because of no dead angle around the aneurysm and the minimum retraction required for the brain and optic nerve. Surgical approaches to subchiasmal carotidophthalmic aneurysms are discussed.

✓ The majority of patients with intracranial hemorrhage associated with moyamoya disease have been described as having subarachnoid hemorrhage (SAH), but it seems doubtful that moyamoya disease causes primary SAH. Computerized tomography (CT) has revealed that most of the hemorrhage found in cases of moyamoya disease is intracerebral or intraventricular. The authors have reviewed 54 cases of intracranial hemorrhage confirmed by CT, including nine of their own, and found that in all but one the bleeding was intracerebral or intraventricular. The single case of SAH was due to rupture of a saccular aneurysm associated with moyamoya disease. It may be concluded from these results that moyamoya disease does not cause primary SAH per se.

In abused children, subdural hematoma is one of the most common causes of damage to the central nervous system. We report six Japanese cases of child abuse with subdural hematoma and discuss differences from those in the United States. The majority of abused children with subdural hematomas in Japan have suffered direct violence to the face and head, resulting in external signs of trauma. Failure to detect these external traces of trauma, however, might result in an incorrect diagnosis of infantile acute subdural hematoma attributed to accidental trivial head injury. Child abuse with subdural hematoma in the United States is frequently caused by whiplash shaking injury in which external signs of trauma may not be evident. In the United States, retinal hemorrhage and subdural hematoma together suggest child abuse; some cases of infantile acute subdural hematoma might be mistakenly diagnosed as child abuse. Thus, the constellation of retinal bleeding and subdural hematoma combined with the absence of visible signs of trauma is differently interpreted in the United States and Japan.

The author reports a unique case of a neonate with a depressed skull fracture detected immediately below a cephalhematoma complicated with an epidural hematoma. The epidural hematoma communicating with the cephalhematoma through a depressed skull fracture disappeared after the cephalhematoma was punctured for aspiration, and the depressed fracture reduced spontaneously 6 months thereafter.

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 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.

Two cases of infantile hydrocephalus are reported, in which the ventricular shunt proved to function despite the catheter tip being located outside the ventricular system, as revealed by computed tomography. This condition could be erroneously diagnosed as arrested hydrocephalus or proximal shunt malfunction, with a resultant potential risk of inadequately removing the catheter.

✓ Twenty-six cases of infantile acute subdural hematoma treated between 1972 and 1983 were reviewed. The series was limited to infants with acute subdural hematoma apparently due to minor head trauma without loss of consciousness, and not associated with cerebral contusion. Twenty-three of the patients were boys, and three were girls, showing a clear male predominance. The patients ranged in age between 3 and 13 months, with an average age of 8.1 months, the majority of patients being between 7 and 10 months old. Most of the patients were brought to the hospital because of generalized tonic convulsion which developed soon after minor head trauma, and all patients had retinal and preretinal hemorrhage. The cases were graded into mild, intermediate, and fulminant types, mainly on the basis of the level of consciousness and motor weakness. Treatment for fulminant cases was emergency craniotomy, and that for mild cases was subdural tapping alone. For intermediate cases, craniotomy or subdural tapping was selected according to the contents of the hematoma. The follow-up results included death in two cases, mild physical retardation in one case, and epilepsy in one case. The remaining 23 patients showed normal development. The relationship between computerized tomography (CT) findings and clinical grading was analyzed. Because some mild and intermediate cases could be missed on CT, the importance of noting the characteristic clinical course and of funduscopic examination is stressed.

A standard three-point skull clamp is modified for application to infants. Rubber plugs (usually used for antibiotic bottles) pierced by the skull pins are used to avoid intracranial penetration of the pins. The upper surface of the rubber plugs attached to the scalp contributes to support of the head. Four infants were successfully treated in a prone position with this technique.

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.

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.

Four premature infants weighing less than 2,500 grams underwent lumboperidoneal shunt for their communicating hydrocephalus. Using a microscope, mini-laminectomy and exact placement of the proximal end of the shunt tube into the subarachnoid space was achieved. After the lumboperitoneal shunting, hydrocephalus in all four patients was relieved without any complications. The author discusses the availability of lumboperitoneal shunt for hydrocephalus in premature infants.

We present an extremely rare case of an arteriovenous malformation (AVM) in the territory of the middle cerebral artery, the main trunk of which was occluded asymptomatically. Immediately after an uneventful excision of the entire AVM, massive brain swelling occurred unexpectedly and was treated successfully with high dose barbiturate therapy associated with other standard measures of controlling increased intracranial pressure. The underlying pathophysiological mechanisms leading to the massive intraoperative brain swelling in this case are discussed.

An adult case of intracerebellar hematoma with a definite capsule is presented. The hematoma is thought to have been enlarged by repeated hemorrhages inside the capsule, with consequent progressive neurological symptoms. Intracerebellar hematoma does not always disappear by absorption. On the contrary, it may expand, and symptoms and signs similar to those of cerebellar tumor may subsequently develop. The authors propose that the expanding intracerebellar hematoma is a possible clinicopathological entity with a definite capsule comparable to that of chronic subdural hematoma.

✓ The author reports a case in which a subchiasmal carotid-ophthalmic artery aneurysm was clipped through a bifrontal interhemispheric approach. This approach is feasible for carotid-ophthalmic artery aneurysms with a variety of anatomical correlations between the optic nerve and the aneurysmal neck.

An infant who suffered acute subdural hematoma due to minor head trauma twice in a short period is presented. Each subdural hematoma, showing high density on computed tomographic scanning, resolved with unusual rapidity, resulting in full recovery after nonsurgical management. The mechanism of this rapid resolution of each hematoma was thought to be participation of cerebrospinal fluid secondary to a tearing of the arachnoid membrane.

A case of intracerebellar hematoma in infancy is reported. Although the clinical course and computed tomographic appearances suggested a cerebellar tumor, intraoperative and microscopic investigations demonstrated a chronic expanding hematoma enlarging with repeated hemorrhages inside the capsule. The differential diagnosis of this entity is discussed.

An 11-year-old boy with Down syndrome is presented who suffered progressive hemiparesis on the left side for a period of 5 years. Computed tomography demonstrated a large cyst of the septum pellucidum and a calcified spot in the head of caudate nucleus on the right side. By penetrating the cyst wall to create a communication into the lateral ventricle, shrinkage of the cyst and improvement of the hemiparesis were obtained. The pathogenesis of the hemiparesis was presumed to be attributed to circulatory compromise in the deep cerebral veins, secondary to the cyst.

✓ Twenty-six cases of infantile acute subdural hematoma treated between 1972 and 1983 were reviewed. The series was limited to infants with acute subdural hematoma apparently due to minor head trauma without loss of consciousness, and not associated with cerebral contusion. Twenty-three of the patients were boys, and three were girls, showing a clear male predominance. The patients ranged in age between 3 and 13 months, with an average age of 8.1 months, the majority of patients being between 7 and 10 months old. Most of the patients were brought to the hospital because of generalized tonic convulsion which developed soon after minor head trauma, and all patients had retinal and preretinal hemorrhage. The cases were graded into mild, intermediate, and fulminant types, mainly on the basis of the level of consciousness and motor weakness. Treatment for fulminant cases was emergency craniotomy, and that for mild cases was subdural tapping alone. For intermediate cases, craniotomy or subdural tapping was sele...

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.

✓ Two cases of acute epidural hematoma with rapid resolution followed by a benign clinical course are reported. Because of the concomitant increase in the epicranial hematoma over a linear skull fracture in each case, the acute epidural hematoma was presumed to have been decompressed into the epicranial region through the fracture line.

Unique CT findings were obtained in four cases of acute toxic encephalopathy, including two cases of clinical Reye's syndrome in the acute stage. Common findings in these cases were symmetrical low density in the thalami and the cerebellum (mainly the dentate nuclei) and similar changes in the surroundings of the lateral ventricles.

For surgery of upper basilar artery aneurysms, we have modified the temporopolar approach proposed by Sano by detaching the zygomatic arch to obtain a wide, shallow operating field. This approach seems to be suitable for anteriorly protruding, high-positioned, or large aneurysms of the upper basilar artery. We have used this zygomatic temporopolar approach in 4 patients with such aneurysms and obtained satisfactory results. In this paper, we detail the operative procedure and emphasize certain technical points to minimize temporal lobe retraction and to prevent oculomotor and facial nerve injuries.

A new technique for the treatment of chronic subdural hematoma by tapping and irrigation was shown by computed tomography to be safe and reliable in 39 patients. The basis for such treatment is discussed in light of the current theories of the pathogenesis of chronic 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.

A new technique for the treatment of chronic subdural hematoma by tapping and irrigation was shown by computed tomography to be safe and reliable in 39 patients. The basis for such treatment is discussed in light of the current theories of the pathogenesis of chronic subdural hematoma.

✓ Two pediatric patients with acute epidural hematomas containing air bubble(s) are reported. A skull fracture was observed extending to the mastoid cells of the temporal bone in both patients. In one patient the hematoma and air bubbles subsequently increased in volume, requiring a craniotomy. The clinical significance of air in an acute epidural hematoma is discussed.

Although lumboperitoneal (LP) shunts have come to be widely used in the treatment of communicating hydrocephalus, LP shunts are not indicated for patients with intraperitoneal pathological conditions. The author, therefore, devised a technique to divert the distal and of an LP shunt into the right atrium via femoral catheterization. The patient had received an LP shunt for normal pressure hydrocephalus, using a medium pressure slit valve and a flushing device in the right lower quadrant of the abdomen. Immediate before gastrectomy for cancer, conversion of a lumboatrial shunt was scheduled.

With a patient in the concorde position, lying prone with the head flexed and tilted laterally, higher than the heart, it is possible to use both the occipital transtentorial and infratentorial supracerebellar approaches without changing the patient's position. We report the successful treatment with this combined approach of an arteriovenous malformation in the upper vermis supplied by the superior cerebellar artery.

A case is presented in which the sudden onset of bitemporal hemianopsia was caused by partial thrombosis associated with enlargement of an unruptured anterior communicating artery aneurysm. The features of the sequential computed tomographic scans resembled those of pituitary apoplexy, reemphasizing the necessity for cerebral angiography in preoperative evaluation. The clinical significance of the warning signs of cerebral aneurysm during the era of computed tomography is discussed. (Neurosurgery 22:564-566, 1988)

Communication between bilateral subdural hematoma cavities was not demonstrated by metrizamide computed tomography subdurography in three patients with bilateral chronic subdural hematomas. Because unilateral subdural tapping yielded a slack fontanel without untoward neurological findings, patients were treated by the placement of unilateral subdural-peritoneal shunts, resulting in resolution of the bilateral hematomas.

The case of an infant with hydrocephalic enlargement of the 4th ventricle and dilatation of the basal cisterns is presented. Although the lateral ventricular shunt was proved to be functioning, the patient developed supratentorial hypertension marked by a tense fontanelle. Placement of a 4th ventricle-peritoneum shunt was followed by shrinkage of the 4th ventricle and resolution of the supratentorial hypertension. Work-up, including computed tomographic ventriculography and cisternography, demonstrated occlusion of the aqueduct of Sylvius and of subarachnoid spaces. This unique pathological process, differentiated from an isolated 4th ventricle, could be referred to as communicating 4th ventricular hydrocephalus.

A 57-year-old woman who had hemifacial spasm on the left side for 5 years underwent exploration of the cerebellopontine angle region for the purpose of microvascular decompression. At operation, however, no artery, vein, or other abnormality was noted at the facial nerve root exit zone. Consequently, the exploration was completed without additional manipulation or the placement of a protective barrier, but the patient awoke from the operation completely free of the spasm. The cause of the hemifacial spasm in this patient could not be explained by the currently predominating vascular compression theory.

The author reports a patient whose postoperative course was complicated by the coexistence of subcortical hematoma contralateral to the operative site and tension pneumocephalus. This case report and review of the literature suggest that these two complications are both attributed to the intraoperative procedure, which rapidly and greatly relaxes the brain. The potential risk of neurosurgical procedures for an atrophic brain, in which such complications are apt to occur, is discussed.