Basilar dolichoectasia and the spontaneous intradural vertebral artery dissection.

OBJECT: Basilar dolichoectasia (BD) is an atherosclerotic, a distinct arteriopathy or a chronic-phase dissection characterized by elongation and dilation of the basilar artery. Spontaneous intradural vertebral artery dissection (siVAD) is an important cause of stroke in young and middle-aged people. It is hypothesized that the BD and the siVAD might partially share aetiologies and this study aimed to examine the relationship. METHODS: This study compared clinical and radiological characteristics in 93 patients with siVAD with 93 controls. Ectasia was defined as basilar artery diameter >4.5 mm and dolichosis, as either basilar artery bifurcation above the suprasellar cistern or lateral to the margin of the clivus or dorsum sellae. The BD was defined if both ectasia and dolichosis were simultaneously observed. Multivariate logistic regression analysis was performed using variables that were marginally or significantly associated with siVAD on univariate analysis (p < 0.20). RESULTS: Multivariate analysis showed siVAD patients have higher proportions of hypertension (OR = 2.4; 95% CI = 1.3-4.6; p = 0.007) and BD (OR = 3.7; 95% CI = 1.1-12; p = 0.036). CONCLUSIONS: The present study suggested that BD was related to the siVAD. A randomized study from multi-institutions with an adequate sample size is needed to make a strong argument about the association between BD and siVAD.

Inverse Relationship between Coffee Consumption and Cerebral Microbleeds in Men, but Not Women.

BACKGROUND: Studies evaluating the association between coffee consumption and neurovascular diseases have frequently yielded contradictory results. The aim of this study was to investigate the association of coffee consumption with small-vessel disease (SVD) incidence in a healthy urban population while accounting for multiple demographic and lifestyle risk factors. METHODS: This prospective study conducted from May 2013 through March 2014 included 455 participants (314 men and 141 women) aged 25 to 92 years. All subjects completed a questionnaire on coffee consumption and received a comprehensive neurologic examination, including magnetic resonance imaging, at St. Luke's International Hospital (Tokyo, Japan). RESULTS: Incidence of SVD was lower in male daily coffee drinkers than male nondrinkers and occasional drinkers, whereas incidence of white matter lesions was lower in female daily coffee drinkers than female nondrinkers or occasional drinkers. In multivariate analyses including age, sex, smoking status, and BMI, as well as coffee consumption, incidence of microbleeds was significantly lower in male daily coffee drinkers compared to nondrinkers. CONCLUSIONS: Daily coffee consumption is associated with reduced risk of cerebral microbleeds in men.

Foramen spinosum and middle meningeal artery in moyamoya disease: Preliminary results of a pilot study.

OBJECT: This study investigated whether the size of the middle cranial fossa foramina reflects the severity of moyamoya disease (MMD). METHODS: It compared 20 adult patients managed without surgical revascularization with 2 age- and sex-matched controls. MR angiography scores were assigned by the severity of occlusive changes of the internal carotid artery, the middle cerebral artery, the anterior and the posterior cerebral arteries and the signals of the distal branches of these arteries. These scores were stratified into MR angiography grades (Houkin's grade: 1-4). The relationships between the Houkin's grade and the size of the foramen spinosum (FS), foramen ovale, carotid canal and middle meningeal artery (MMA) were evaluated. RESULTS: Simple regression analysis showed the correlation between the Houkin's grade and the bilateral FS (right, r = 0.56, p = 0.010; left, r = 0.46, p = 0.044) and MMA (right, r = 0.89, p = 0.0050; left, r = 0.47, p = 0.036). It also showed the correlation between the FS and MMA (right, r = 0.53, p = 0.018; left, r = 0.55, p = 0.013). There were no significant differences between the Houkin's grade, the size of the carotid canal and the foramen ovale. CONCLUSIONS: The larger FS and MMA on brain CT, which might be performed for patients suspected of intracranial lesions, could aid the diagnosis of MMD.

Basilar extension and posterior inferior cerebellar artery involvement as risk factors for progression of the unruptured spontaneous intradural vertebral artery dissection.

BACKGROUND AND PURPOSE: Spontaneous intradural vertebral artery dissection (siVAD) primarily causes stroke in young and middle-aged individuals; however, data on the relationship between vertebrobasilar morphology and the progression of siVAD are limited. METHODS: We retrospectively reviewed the data of 77 adult patients who were diagnosed with unruptured siVAD and treated conservatively. We analysed the clinical characteristics, vertebrobasilar morphologies and progression. Progression was defined as siVAD-induced stroke or morphological worsening of the siVAD. RESULTS: Twenty patients experienced progression. Recurrent ischaemic events that occurred in the vertebrobasilar territory were seen in three patients (3.9%). Two of these three patients and other 17 patients showed morphological worsening. None of the patients presented with subarachnoid haemorrhage. The log-rank test showed male sex, migraine, basilar extension and the posterior inferior cerebellar artery involvement were associated with the progression. Multivariate analysis using the Cox proportional hazards model showed that only basilar extension and the posterior inferior cerebellar artery involvement were significantly related to the progression (p=0.012 and 0.019). In addition, patients with these two vertebrobasilar morphologies had a significantly shorter period of progression of siVAD than those without these morphologies (both, median 242 days; one of two, median 1292 days; none, median 2445 days). CONCLUSIONS: Thus, some vertebrobasilar morphologies might be markers of the progression of unruptured siVAD. Although all unruptured siVAD patients should be closely monitored, those with basilar extension and posterior inferior cerebellar artery involvement should perhaps be more carefully followed than those without such morphologies.

Morphological and clinical risk factors for posterior communicating artery aneurysm rupture.

OBJECT: Recent studies have shown that posterior circulation aneurysms, specifically posterior communicating artery (PCoA) aneurysms, are more likely to rupture than other aneurysms. To date, few studies have investigated the factors contributing to PCoA aneurysm rupture. The authors aimed to identify morphological and clinical characteristics predisposing to PCoA aneurysm rupture. METHODS: The authors retrospectively reviewed 134 consecutive patients with PCoA aneurysms managed at their facility between July 2003 and December 2012. The authors divided patients into groups of those with aneurysmal rupture (n = 39) and without aneurysmal rupture (n = 95) and compared morphological and clinical characteristics. Morphological characteristics were mainly evaluated by 3D CT angiography and included diameter of arteries (anterior cerebral artery, middle cerebral artery, and internal carotid artery), size of the aneurysm, dome-to-neck ratio, neck direction of the aneurysmal dome around the PCoA (medial, lateral, superior, inferior, and posterior), aneurysm bleb formation, whether the PCoA was fetal type, and the existence of other intracranial unruptured aneurysm(s). RESULTS: Patients with ruptured PCoA aneurysms were significantly younger (a higher proportion were < 60 years of age) and a significantly higher proportion of patients with ruptured PCoA aneurysms showed a lateral direction of the aneurysmal dome around the PCoA, had bleb formation, and the aneurysm was > 7 mm in diameter and/or the dome-to-neck ratio was > 2.0. Multivariate logistic regression analysis showed age < 60 years (OR 4.3, p = 0.011), history of hypertension (OR 5.1, p = 0.008), lateral direction of the aneurysmal dome around the PCoA (OR 6.7, p = 0.0001), and bleb formation (OR 11, p < 0.0001) to be significantly associated with PCoA aneurysm rupture. CONCLUSIONS: The present results demonstrated that lateral projection of a PCoA aneurysm may be related to rupture.

Acute alcohol intoxication, diffuse axonal injury and intraventricular bleeding in patients with isolated blunt traumatic brain injury.

OBJECTIVE: The influence of blood alcohol level (BAL) on outcome remains unclear. This study investigated the relationships between BAL, type and number of diffuse axonal injury (DAI), intraventricular bleeding (IVB) and 6-month outcome. METHODS: This study reviewed 419 patients with isolated blunt traumatic brain injury. First, it compared clinical and radiological characteristics between patients with good recovery and disability. Second, it compared BAL among DAI lesions. Third, it evaluated the correlation between the BAL and severity of IVB, number of DAI and corpus callosum injury lesions. RESULTS: Regardless of BAL, older age, male gender, severe Glasgow Coma Scale score (<9), abnormal pupil, IVB and lesion on genu of corpus callosum were significantly related to disability. There were no significant differences between the BAL and lesions of DAI. Simple regression analysis revealed that there were no significant correlation between BAL and severity of IVB, number of DAI and corpus callosum injury lesions. CONCLUSIONS: Acute alcohol intoxication was not associated with type and number of DAI lesion, IVB and disability. This study suggested that a specific type of traumatic lesion, specifically lesion on genu of corpus callosum and IVB, might be more vital for outcome.

Morphological and clinical risk factors for the rupture of anterior communicating artery aneurysms.

OBJECT: Patients with ruptured anterior communicating artery (ACoA) aneurysms have historically been observed to have poor neuropsychological outcomes, and ACoA aneurysms have accounted for a higher proportion of ruptured than unruptured aneurysms. Authors of this study aimed to investigate the morphological and clinical characteristics predisposing to ACoA aneurysm rupture. METHODS: Data from 140 consecutive patients with ACoA aneurysms managed at the authors' facility between July 2003 and November 2011 were retrospectively reviewed. Patients with (78) and without (62) aneurysm rupture were divided into groups, and morphological and clinical characteristics were compared. Morphological characteristics were evaluated based on 3D CT angiography and included aneurysm location, dominance of the A1 portion of the anterior cerebral artery, direction of the aneurysm dome around the ACoA, aneurysm bleb(s), size of the aneurysm and its neck, aneurysm-parent artery angle, and existence of other intracranial unruptured aneurysms. RESULTS: Patients with ruptured ACoA aneurysms were significantly younger (a higher proportion were younger than 60 years of age) than those with unruptured lesions, and a significantly smaller proportion had hypercholesterolemia. A significantly larger proportion of patients with ruptured aneurysms showed an anterior direction of the aneurysm dome around the ACoA, had a bleb(s), and/or had an aneurysm size ≥ 5 mm. Multivariate logistic regression analysis showed that an anterior direction of the aneurysm dome around the ACoA (OR 6.0, p = 0.0012), the presence of a bleb(s) (OR 22, p < 0.0001), and an aneurysm size ≥ 5 mm (OR 3.16, p = 0.035) were significantly associated with ACoA aneurysm rupture. CONCLUSIONS: Findings in the present study demonstrated that the anterior projection of an ACoA aneurysm may be related to rupturing. The authors would perhaps recommend treatment to patients with unruptured ACoA aneurysms that have an anterior dome projection, a bleb(s), and a size ≥ 5 mm.

Impact of body mass index on the location of spontaneous intracerebral hemorrhage.

BACKGROUND: Although there have been some reports regarding body mass index (BMI) and subtypes of stroke, there have been few concerning the relationship between BMI and location of spontaneous intracerebral hemorrhage (ICH). Determining the location of spontaneous ICH is important because outcome is thought to be affected by its location. The aim of this study was to determine whether location of spontaneous ICH varied according to BMI level. METHODS: In this retrospective study, 463 patients with spontaneous ICH were divided into 3 groups according to BMI (kg/m(2)): <18.5 (underweight), 18.5 to 24.0 (normal weight), 24.0 to 29 (overweight), and >29.0 (obesity). We compared the clinical characteristics among patients with putaminal, thalamic, lobar, pontine, or cerebellar hemorrhage on univariate and multinominal logistic regression analysis. RESULTS: Among the 5 locations, BMI level was lowest in patients with lobar hemorrhage and highest in those with pontine hemorrhage. Compared to patients with nonlobar hemorrhage, patients with lobar hemorrhage showed a higher proportion of individuals who were underweight, female, and age >70 years and a lower proportion who were hypertensive. Compared with patients with nonpontine hemorrhage, those with pontine hemorrhage showed a higher proportion of individuals who were obese. CONCLUSIONS: Our findings indicate that BMI can affect the location of spontaneous ICH.

Differences in vertebrobasilar artery morphology between spontaneous intradural vertebral artery dissections with and without subarachnoid hemorrhage.

BACKGROUND: Patients with spontaneous intradural vertebral artery dissection (siVAD) developing subarachnoid hemorrhage (SAH) have been observed to have poor outcomes. Factors predisposing siVAD patients to SAH are not well known. We aimed to investigate the clinical and vertebrobasilar artery morphological characteristics associated with SAH in patients with siVAD. METHODS: We reviewed 103 consecutive patients with siVAD managed at our facility between July 2003 and June 2012. We divided the patients into groups, with (n = 22) and without (n = 81) SAH, and compared clinical and vertebrobasilar artery morphological characteristics between them. The vertebral-union-basilar angle (VUBA) was defined as the most acute angle between the line of the basilar artery trunk and the line of the vertebral artery at the vertebral union on 3-dimensional magnetic resonance angiography, computed tomographic angiography, or digital subtraction angiography. 'Steep vertebral artery' was defined as VUBA >45°. Basilar artery bending was defined as the longest distance from the line which connected the basilar top and vertebral artery union to the greatest bending point of the basilar artery. RESULTS: Stepwise logistic regression analysis was performed using variables that were marginally or significantly associated with SAH on univariate analysis (p < 0.10) and that were thought to be clinically important for SAH. It showed SAH patients to have significantly higher proportions of current smoking (OR: 7.7; 95% CI: 2.7-22; p = 0.0015), dissection of the dominant vertebral artery (OR: 4.9; 95% CI: 1.8-13; p = 0.043), steep vertebral artery of the dissecting side (OR: 7.2; 95% CI: 2.6-20; p = 0.0023), posterior inferior cerebellar artery involvement (OR: 4.0; 95% CI: 1.3-13; p = 0.011), basilar artery bending <3 mm (OR: 3.4; 95% CI: 1.3-9.5; p = 0.0040), and pearl-and-string sign (OR: 5.7; 95% CI: 2.0-16; p = 0.0033). CONCLUSIONS: We suggest that the clinical and vertebrobasilar artery morphological characteristics demonstrated in the present study may be related to SAH induced by siVAD. Although all patients with siVAD should be closely monitored, those with siVAD who have these characteristics should perhaps be more closely followed than those who do not have such features.

Intraventricular hemorrhage on computed tomography and corpus callosum injury on magnetic resonance imaging in patients with isolated blunt traumatic brain injury.

OBJECT: Intraventricular hemorrhage (IVH) is widely regarded as one element of a complex involving severe blunt traumatic brain injury (TBI); corpus callosum injury (CCI) is recently considered to be one factor associated with poor outcome in patients with TBI. Although postmortem studies have focused on the relationship between IVH and CCI, there have been few investigations of IVH evidenced on CT scans as a predictor of CCI evidenced on MRI. METHODS: The authors retrospectively reviewed prospectively collected data from 371 patients with blunt TBI, without trauma to the face, chest, abdomen, extremities, or pelvic girdle, requiring immediate therapeutic intervention. Their aim was to investigate whether IVH found on CT predicts CCI on MRI. Clinical and radiological data were collected between June 2003 and February 2011. First, the authors classified patients into groups of those with CCI and those without CCI, and they compared clinical and radiological findings between them. Then, they investigated prognostic factors that were related to the development of disability at 6 months after injury. The outcomes at 6 months after injury were evaluated using the Extended Glasgow Outcome Scale (GOS-E). Finally, the authors evaluated the correlation between the severity of the IVH on CT and the number of CCI lesions on MRI. The severity of the IVH was defined by the number of ventricles in which IVH was seen, and the number of CCI lesions was counted on the MRI study. RESULTS: On multivariate logistic regression analysis, Glasgow Coma Scale score less than 9 (OR 2.70 [95% CI 1.10-6.27]), traffic accident (OR 2.59 [95% CI 1.37-4.93]), and IVH on CT (OR 3.31 [95% CI 1.25-8.49]) were significantly related to CCI. Multivariate analysis also showed that older age (p = 0.0001), male sex (OR 3.26 [95% CI 1.46-8.08], p = 0.0065), Glasgow Coma Scale score less than 9 (OR 8.27 [95% CI 3.39-21.4], p < 0.0001), evidence of IVH on CT (OR 4.09 [95% CI 1.45-11.9], p = 0.0081), and evidence of CCI on MRI (OR 8.32 [95% CI 3.89-18.8], p < 0.0001) were associated with future development of disability (GOS-E score ≤ 6). Furthermore, simple regression analysis revealed the existence of a strong correlation between the severity of IVH and the number of CCI lesions (r = 0.0668, p = 0.0022). CONCLUSIONS: The authors' results suggest that evidence of IVH on CT may indicate CCI, which can lead to disability in patients with isolated blunt TBI.

Relationships among hematoma diameter, location categorized by vascular territory, and 1-year outcome in patients with cerebellar hemorrhage.

OBJECTIVE: Some studies have investigated the relationship between anatomic location and outcome in patients with cerebellar hemorrhage (CH), but not as yet the relationship between location of CH, as categorized according to vascular territory, and outcome. Furthermore, other studies have shown that taking antithrombotics was related to having CH; however, there have been no studies assessing the relationship between antithrombotics and the location of CH. The aim of this study was to determine whether the outcome of patients with CH at 1-year after onset differed depending on antithrombotic use and lesion location. METHODS: A retrospective, single-institution study involving 53 patients with CH was conducted. Location of the CH, categorized by vascular territory, was classified as either superior cerebellar artery hemorrhage (SCAH), anterior inferior cerebellar artery hemorrhage, or posterior inferior cerebellar artery hemorrhage. Outcome was evaluated using the modified Rankin scale (mRS) and mRS was divided into good (mRS ≤2) or poor (mRS ≥3). RESULTS: Thirty-four patients had SCAH, 5 had anterior inferior cerebellar artery hemorrhage, and 14 had posterior inferior cerebellar artery hemorrhage. Patients with poor outcome had higher proportions of Glasgow coma scale score ≤8, SCAH, intraventricular bleeding, hydrocephalus, and maximal transverse diameter ≥30 mm by univariate analysis. After multivariate analysis, Glasgow coma scale score ≤8 and SCAH showed a significant association with poor outcome. CONCLUSIONS: Outcome at 1-year after onset differed by location of the CH lesion as categorized according to vascular territory. SCAH was related to poor outcome by a larger maximal transverse diameter of hematoma and hydrocephalus.

Genu of corpus callosum as a prognostic factor in diffuse axonal injury.

OBJECT: Previous studies have shown a relationship between a patient's stage of diffuse axonal injury (DAI) and outcome. However, few studies have assessed whether a specific lesion or type of corpus callosum injury (CCI) influences outcome in patients with DAI. The authors investigated the effect of various DAIs and CCIs on outcome in patients with traumatic brain injury (TBI). METHODS: The authors retrospectively reviewed 78 consecutive patients with DAI who were seen between May 2004 and March 2010. Outcome was evaluated using the Extended Glasgow Outcome Scale (EGOS) 1 year after TBI. Patients with single DAIs had only 1 of the 3 lesions (lobar, CC, or brainstem). Patients with dual DAIs had 2 of these lesions, and those with triple DAIs had all of these lesions. Furthermore, the authors defined single, dual, and triple CCIs by using 3 lesions (genu, body, splenium) in the same way among patients with single (CC) DAIs. Univariate and multivariate logistic regression analyses were performed to evaluate the relationships between these lesions and outcome in patients with DAI. RESULTS: Fifty patients had single DAIs: 34 in the lobar area, 11 in the CC, and 5 in the brainstem. Twenty had dual DAIs, and 8 had triple DAIs. Of the 11 CCIs, 9 were single and 2 were dual CCIs. Among these lesions, only those in the genu were related to disability. The authors dichotomized patients into those with and without genu lesions, regardless of other injuries. Multinomial logistic regression analysis showed that a genu lesion (OR 18, 95% CI 2.2-32; p = 0.0021) and a pupillary abnormality (OR 14, 95% CI 1.6-24; p = 0.0068) were associated with disability (EGOS ≤ 6) in patients with DAI. CONCLUSIONS: Regardless of the number of lesions, the existence of a genu lesion suggested disability 1 year after TBI in patients with DAI.

Genu of corpus callosum in diffuse axonal injury induces a worse 1-year outcome in patients with traumatic brain injury.

BACKGROUND: Previous studies have shown a relationship between diffuse axonal injury (DAI) and unfavorable clinical outcome in patients with traumatic brain injury (TBI), but it remains unclear whether the type of DAI lesion influences outcome after TBI. The aim of the present study was to investigate whether 1-year outcome after TBI differed between patients with different types of lesions. METHODS: A retrospective, single-institution study involving 261 patients with TBI was carried out between April 2003 and December 2009. Outcome was measured using the Glasgow Outcome Scale (GOS) 1 year after TBI. DAI lesions occurred in the lobar region, corpus callosum (CC), and brainstem. CC lesions were subdivided into three types: genu, body, and splenium. Univariate and multivariate logistic regression analyses were performed to evaluate the relationships between clinical characteristics and outcome for each type of DAI lesion and each type of CC lesion in patients with TBI. FINDINGS: Sixty-nine patients had DAI lesions: 34 in the lobar region, 30 in the CC, and five in the brainstem. Of the 30 patients with CC lesions, ten each were found in the genu, body, and splenium. Each DAI, CC, and genu lesion was significantly associated with unfavorable outcome 1 year after TBI by multivariate analysis using variables that were significantly associated with unfavorable outcome as determined by univariate analysis after adjustment for age. CONCLUSIONS: CC lesions, especially those in the genu, were related to unfavorable 1-year outcome in patients with TBI.

Comparison of clinical characteristics and MR angiography appearance in patients with spontaneous intradural vertebral artery dissection with or without subarachnoid hemorrhage.

OBJECT: It is well known that spontaneous intradural vertebral artery dissection (siVAD) is an important cause of nontraumatic subarachnoid hemorrhage (SAH). The factors that influence whether SAH develops, however, remain unclear. The aim of this study was to investigate whether clinical characteristics and imaging findings are different in patients with siVAD with SAH compared to those with siVAD without SAH. METHODS: The authors conducted a retrospective, single-institution study involving patients in whom siVAD developed with or without SAH, between July 2003 and November 2010. Univariate and multivariate analyses were performed to evaluate clinical characteristics and MR angiography findings. The vertebral-union-basilar angle (VUBA) was defined as the most acute angle between line of the basilar artery trunk and line of the vertebral angle (VA) at the vertebral union on 3D MR angiograms. RESULTS: Among 58 patients with siVAD, 21 developed SAH. The presence of siVAD and SAH was significantly associated with higher rates of current smoking (OR 13; 95% CI 3.6-38; p < 0.0001), dissection of the dominant VA (OR 9.2; 95% CI 2.5-19; p = 0.0004), and unruptured supratentorial nondissecting saccular aneurysms (OR 11; 95% CI 2.1-19; p = 0.0025), and the VUBA of the dominant VA was significantly larger (p < 0.0001, univariate analysis). Multivariate analysis showed that these differences were still significant (p < 0.05). CONCLUSIONS: A larger VUBA of the dominant VA, the presence of unruptured supratentorial nondissecting saccular aneurysms, and current smoking may be factors that predict which patients with siVAD will develop SAH by dominant VAD.

Antiplatelet agents are risk factors for cerebellar hemorrhage in patients with primary intracerebral hemorrhage.

Some reports have suggested that the location of primary intracerebral hemorrhage (ICH) is affected by oral antithrombotic agents (ATs). This is important, given the increasing use of ATs to treat arteriosclerotic disease. The aim of this study was to explore whether oral AT therapy increase the incidence of any specific location of primary ICH. A retrospective, single-institution study involving 410 Japanese patients with primary ICH was conducted between July 2003 and June 2009. Bivariate analyses (ie, Fisher's exact 2-tailed test, Student's t test, Welch's test, Wilcoxon's rank-sum test, Pearson's χ(2) test) and multivariate logistic regression analysis were performed for clinical characteristics of these patients. Of the 410 patients, 20% were taking ATs before the onset of primary ICH. The incidence of cerebellar hemorrhage (CH) exceeded that of other types of hemorrhage in patients taking ATs, and the difference was statistically significant on bivariate analysis (P < .0001). On multivariate analysis, only antiplatelet (AP) therapy was found to significantly increase the frequency of CH in patients with primary ICH (P = .0035). Our data indicate that taking APs before the onset of ICH a related factor for CH in Japanese patients with primary ICH.

Significance of preoperative position of the femoral head in failed closed reduction in developmental dislocation of the hip: surgical results.

Long-term follow-up results of open reduction for developmental dislocation of 83 hips via the extensive anterolateral approach were retrospectively analyzed. Open reduction was performed in infancy, and the follow-up period ranged from 12 to 24 years. This procedure is a complete circumferential dissection of the joint capsule and produces sufficient concentric reduction of the femoral head in the acetabulum immediately after the surgery. A lateral arthrographic classification of interposed limbus and the preoperative position of the unreduced femoral head is introduced, and is related to operative findings and surgical results, including Severin's classification. The results at the final follow-up were: Severin's group I in 35 hips, group II in 19 hips, group III in 10 hips, and group IV in four hips. According to the classification of the preoperative position of the femoral head, there were 31 hips of the intracapsular type and 37 hips of the extracapsular type. Thirty-four of the 37 hips of the extracapsular type were classified in Severin's group I or II (92%). Twenty of the 31 hips of the intracapsular type were classified in Severin's group I or II (65%). A very significantly greater number of hips with good radiological outcome were in the extracapsular type than in the intracapsular type.