Surgical management of symptomatic intrasellar arachnoid cysts--two case reports.

Two patients with symptomatic intrasellar arachnoid cyst were successfully treated. A 67-year-old female with a cyst 20 mm in diameter developed headache and visual disturbance. She was treated by transsphenoidal surgery. A 59-year-old male with a cyst measuring 35 x 30 x 50 mm causing headache, visual disturbance, and deterioration of consciousness was managed by wide resection of the cyst wall via craniotomy. Postoperative courses in both patients were uneventful. Transsphenoidal surgery may be suitable for small to medium-sized cysts, although tight packing of the sella is mandatory to prevent leakage of cerebrospinal fluid. However, craniotomy is recommended for large intra- and suprasellar arachnoid cysts to avoid this complication, and to achieve sufficient communication between the cyst and the subarachnoid cistern.

[A case of metastatic intracerebral malignant schwannoma].

A 53 year old male complaining of headache and left hemiparesis was referred to our hospital on November 11, '89. He had no evidence of von Recklinghausen's disease. He had been operated on because of a well circumscribed tumor in the left paravertebral muscle on July 11, '87, and metastasis in the lower lobe of the left lung on April 20, '88. The pathological diagnosis of both the primary and the metastatic lung tumor was malignant peripheral nerve sheath tumor showing peripheral cell differentiation (malignant schwannoma). Contrast enhanced CT demonstrated an irregularly enhanced mass in the right parietal lobe just before admission. On the night of admission November 12, '89, he suddenly had severe headache and this progressed to hemiparesis. Repeat CT examination was done immediately and revealed intratumoral hemorrhage. On November 19, '89, the tumor was totally removed. His symptoms disappeared postoperatively. The pathological findings of the tumor were the same as those made previously. The patient received radiotherapy to the brain (local 50 Gy and whole brain 30 Gy) and chemotherapy with nitrosourea (MCNU 150mg). He was discharged without neurological deficits. However he had two operations to remove metastatic tumors in the soft tissue of the hip on January 12, and August 17, '90. A very rare case of metastatic intracerebral malignant schwannoma is reported, and the literature on this point is reviewed.

[A case of chronic subdural hematoma associated with idiopathic thrombocytopenic purpura (ITP)].

A 41-year-old male was admitted to our service with right occipital pain as his chief complaint. CT and MRI examinations revealed bilateral chronic subdural hematomas. The patient had also been affected with ITP since the age of 28. Since emergency operation was thought to be dangerous, he was transferred to Tokushima University Hospital, and treated preoperatively by administration of steroids and a large dose of immunoglobulin. When his platelet count had returned to 146,000/mm3, evacuation of the hematoma through burr holes was performed successfully under local anesthesia. The postoperative course was uneventful. So far as we have been able to find in the literature, only 3 cases of ITP complicated by chronic subdural hematoma have been reported. The characteristic clinical feature of these 4 cases including our own case was noted as the absence of a history of trauma. However, the etiological relationship between ITP and chronic subdural hematoma was controversial. Occurrence of chronic subdural hematoma in patients with ITP and in patients under hemodialyzer treatment is very rare. However, intracerebral hemorrhages are rather common among such patients. So it was suggested that the tendency to bleeding among patients with ITP, and among hemodialyzer patients may contribute little as an etiological factor in the evolution of chronic subdural hematoma.

[An autopsy case of primary intracranial squamous cell carcinoma].

An autopsied case of primary intracranial squamous cell carcinoma (PISCC) is reported, and 25 previously reported cases of PISCC, followed by the Garcia's criteria, are reviewed. A 72-year-old female was admitted to our service with chief complaints of headache and nausea on March 30, 1988. She had no neurological deficits on admission. However, CT examination revealed a round mass lesion in the left hypothalamus with dislocation of the brain stem. The cerebrospinal fluid (CSF) examination showed squamous cell carcinoma cytologically, and slightly higher levels of beta-HCG (13.0 ng/ml) and CEA (14.2 ng/ml). Because of progressive worsening in the level of her consciousness, total removal of a suprasellar tumor was performed on April 19, 1988. Gross appearance of the tumor was yellowish, soft and encapsulated. Histologically, it was squamous cell carcinoma. She did well for several days after the operation, then deteriorated. Finally she expired because of dissemination of the carcinoma on May 14, 1988. Postmortem examination revealed a large mass of squamous cell carcinoma in her right cerebellopontine angle. Except for that in the brain, no cancer was found in her body. Immunohistological study of the tumor specimen demonstrated positive for HCG in some of the large-sized neoplastic cells. Twenty-six cases of PISCC have been reported previously, so far. However, 21 cases out of the 26 PISCC were thought to have originated from intracranial epidermoid, one from the dermoid and the other one from craniopharyngioma. In the other three cases of PISCC, including the present case, the origin of the tumor was not able to be identified.(ABSTRACT TRUNCATED AT 250 WORDS)

Computed tomography controlled aspiration surgery for hypertensive intracerebral hemorrhage. Experience of more than 400 cases.

To overcome the disadvantages of conventional surgery, we developed our own method of computed tomography controlled stereotactic aspiration surgery for hypertensive intracerebral hemorrhage. A new ultrasonic surgical aspirator was also developed to facilitate aspiration of a dense clot in the acute stage. Between 1980 and 1988, 437 patients with hypertensive intracerebral hemorrhage underwent aspiration surgery. Computed tomography controlled stereotactic aspiration surgery can be performed in hematomas of any site or any stage with minimal tissue damage, even in aged patients. Aspiration surgery led to a favorable clinical experience and outcome, especially in the acute stage.