[Functional outcome of primary pontine hemorrhage: conservative treatment or stereotaxic surgery].

In this study we compared the outcome of patients with primary pontine hemorrhage (PPH) in those who underwent stereotaxic aspiration and those treated non-surgically. Out of 75 PPHs, 37 patients were selected. Their consciousness on admission was somnolent to semicoma (alert and deeply comatose cases were excluded). Patients admitted between 1988 and 1990, and between 1995 and 1996 underwent CT guided stereotaxic aspiration (18 cases: Surgical Group), and those admitted between 1991 and 1994 were treated conservatively (19 cases: Conservative Group). The outcome was analyzed three months after the onset from the viewpoint of level of consciousness and severity of paresis, according to the location of the hemorrhage. With regard to consciousness, 13 of 18 cases in the Surgical Group showed remarkable improvement, while only 8 of 19 cases in the Conservative Group did. The severity of paresis was evaluated only among the patients who could obey commands three months after the onset. Paresis improved in 7 of 13 patients in the Surgical Group, vs. in 3 of 8 patients in the Conservative Group (p < 0.05). According to the location of hemorrhage (CT classification), in the Unilateral tegmental type and the Massive type, the Surgical Group and the Conservative Group showed no difference. On the other hand, in the Bilateral tegmental type and the Basal tegmental type, surgery seemed to be more effective than conservative treatment. In conclusion, CT guided stereotaxic aspiration may improve not only the consciousness level but also the functional outcome.

Mesh-and-glue technique to prevent leakage of cerebrospinal fluid after implantation of expanded polytetrafluoroethylene dura substitute--technical note.

Expanded polytetrafluoroethylene (ePTFE) can be used as a dura substitute but is associated with leakage of cerebrospinal fluid (CSF) through the suture line. Fibrin glue alone may not prevent this problem. This new method for sealing the suture line in ePTFE membrane uses an absorbable polyglycoic acid mesh soaked with fibrinogen fluid placed on the suture line. Thrombin fluid is then slowly applied to the wet mesh, forming a large fibrin membrane reinforced by the mesh over the suture line. Only one of 33 patients in whom this technique was used had CSF leakage, whereas 12 of 59 patients in whom a dural defect was closed with ePTFE alone showed postoperative subcutaneous CSF collection (p < 0.05). Our clinical experiences clearly show the efficacy of the mesh-and-glue technique to prevent CSF leakage after artificial dural substitution. Mesh and glue can provide an adequate repair for small dural defect. The mesh-and-glue technique may also be used for arachnoid sealing in spinal surgery.

Angioplasty for the infusion of fasudil hydrochloride to treat cerebral symptomatic vasospasm.

The present report describes the successful treatment of cerebral symptomatic vasospasm (SVS) after subarachnoid hemorrhage (SAH) with super-selective intra-arterial infusion of fasudil hydrochloride (ERIL((R))). We treated seventeen vascular territories in 12 patients with selective intra-arterial infusion of fasudil hydrochloride (FSD). FSD was infused through a catheter (a microcatheter in nine patients) at a rate of 1.0 to 1.5 mg/minute (total dose=30 to 60mg/1 vessel) for each vascular territory. Nineteen vascular territories (100%) were angiographically dilated and seven patients (58%) showed early improvement in neurological function after the procedure.

[Clear cell ependymoma--a case report].

A case of intraaxial clear cell ependymoma is reported. A 46-year-old man complained of right hemiparesis. CT scan showed a mass lesion on the median plane with a huge cyst in the left frontal lobe. MRI showed an iso-low intensity mass by T1-weighted image. The tumor was heterogeneously enhanced by Gd-DTPA and the wall was enhanced as well. Angiogram revealed a tumor stain from the right internal carotid artery. The main mass of the tumor was totally removed but the cystic wall was left removed. Histopathological examination revealed clear cell ependymoma. Immunohistochemical examination revealed that, although vimentin and NSE were positive, GFAP, synaptophysin and S-100 were negative. Ultrastructual examination revealed cilia, microvilli and desmosomal junctions. The patient fully recovered after operation and showed no sign of recurrence after an year of follow-up. Clear cell ependymoma is a rare variant of ependymoma. Ultrastructual examination was more useful than immunohistochemical examination for diagnosis.

Subdural empyema caused by hematogenous dissemination from an abscess in thigh to a preexisting chronic subdural hematoma--case report.

A 63-year-old male with a preexisting chronic subdural hematoma presented with progressive confusion and left hemiparesis as well as high fever. Subdural empyema was strongly suspected. At surgery, the empyema was encapsulated by definite inner and outer membranes. Cultures isolated from the subdural fluid and from an abscess of his left thigh yielded methicillin-resistant Staphylococcus aureus. A pulsed-field gel electrophoresis showed these two strains were genetically identical. Hematogenous infection of a preexisting subdural hematoma is an extremely rare cause of subdural empyema.

[Clinical significance of thrombocytopenia associated with hemorrhagic cerebrovascular diseases].

We investigated the clinical significance of thrombocytopenia (platelet counts less than 10 x 10(4)/mm3) associated with hemorrhagic cerebrovascular disease. This study was conducted in 96 patients suffering from hemorrhagic cerebrovascular diseases. We divided the clinical course into 3 stages: acute (from the 1st to 7th day), subacute (8th-21st day) and chronic (after the 22nd day). The average age of the patients with thrombocytopenia (TCP) was 60.6 years old. TCP was more frequent in men (81.3%) than in women (18.7%). TCP developed in 18.6% (8/43) of patients with subarachnoid hemorrhage (SAH) and in 15.1% (8/53) of those with intracerebral hemorrhage (ICH). Among the patients with SAH, four were in the acute stage, three in the subacute stage and two in the chronic stage. TCP due to SAH was more likely to develop in the acute and/or subacute stage. TCP due to SAH showed two peak appearances: the first was within 24 hours (n = 3), and the second was around 10 days after onset (n = 3). The cause of TCP in its late peak appearance was presumed to be the consumption of platelets due to microembolism induced by vasospasm and/or hemodilution therapy. Among patients with ICH, five cases were in the acute stage, three in the subacute stage and two in the chronic stage. TCP due to ICH was more likely to develop in the acute stage. Fifty percent (4/8) of the patients with ICH had TCP on admission. This data suggested that TCP was possibly a cause or an inducer for ICH.(ABSTRACT TRUNCATED AT 250 WORDS)

[Intracranial hematoma associated with acquired immunodeficiency syndrome (AIDS): case report].

The authors report a case of intracranial hematoma associated with AIDS. A male aged 21 had been treated with infusion of factor VIII to control hemophilia A. He fell down and hit his right occipital region. Immediately after the impact, he became comatose. When he was hospitalized 30 minutes after the injury, a herniation sign was recognized. CT scan revealed right acute subdural hematoma that showed mixed density. This hematoma was successfully removed with HITT (hematoma irrigation with trephination therapy) and he recovered almost completely. However he died when the intracerebral hematoma bled suddenly on the 20th day after surgery. We assumed the hematoma was related to vasculitis induced by AIDS. Three points in this case impressed us. First, HITT is very useful for treating acute subdural hematoma associated with AIDS. Second, the patient's condition may deteriorate suddenly through intracerebral hematoma originating from AIDS-related vasculitis, although the coagulation factors are well maintained. Third, a manual for management of cases of AIDS is necessary to avoid confusion among the medical staff.