No shinkei geka. Neurological surgery
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The combined one-stage operations, STA-MCA anastomosis and internal carotid artery (ICA) ligation (or trapping) were carried out in 11 cases (Age): 18-79 yrs, Av.: 45.8 yrs) of ICA aneurysms which were inaccessible for a direct operation because of their locations and sizes. First the STA-MCA anastomosis was performed under general anesthesia. Then the patient was awaken and thereafter under local anesthesia the ICA was temporarily clamped for 30 min. under induced hypotension to check whether any ischemic signs appeared. ⋯ Intra-arterial pressure measurements of the STA and MCA suggested that the one-stage operations of these two procedures are better than the two-stage operations for the patency of the anastomosis because the pressure gradient between the donor and recipient vessels is increased (from 10.3 mmHg to 49.3 mmHg) by this technique. Temporary ICA clamp for 30 min. under induced hypotension in local anesthesia is useful to check whether the one-stage operations can be tolerated or not. EC/IC bypass with an interposed saphenous vein graft is a more beneficial surgical technique than a routine STA-MCA anastomosis, because an immediate and larger amount of bypass flow can be obtained.
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Cerebral vasospasm after SAH from AVMs is rare. Only few reports have been made. ⋯ This high incidence (31%) might be attributable to the timing from the last SAH attack until angiography. The existence of massive subarachnoid blood clots around the arteries of the circle of Willis is the most important factor causing vasospasm after SAH from AVMs.
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Encapsulated intracerebral hematoma is so rarely seen that only two cases have been reported, by Hirsh et al. Recently, we experienced a case of multilocular encapsulated intracerebral hematoma containing 9 to 10 capsules of different sizes. The capsules of the hematoma were easily dissected from the surrounding brain tissues and found to be grayish white in color, tough in hardness and 1 to 3 mm in thickness. ⋯ These findings indicated the development of intracerebral hematomas with different chronic courses at different times. It is very interesting that the frequency of the convulsive seizure was almost consistent with the number of capsules. For etiology of multilocular intracerebral hematoma, either occult vascular malformation or bleeding from the sinusoidal channel layer of the capsules like that of chronic subdural hematoma is considered.
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CT scan demonstrates the invaluable information about the parenchymal lesions of head injuries. The parenchymal lesions were classified into 6 categories; 1) isodensity without mass effect: I(-), 2) isodensity with mass effect: I(+), 3)high density: H, 4) high-low density complex: H-L, 5) low density: L, 6) diffuse cerebral swelling: DCS. Glasgow coma scale (GCS) and outcome scale (GOS) were international practical scales for the evaluation of severity and prognosis of severe head injuries. ⋯ In the patients, whose prognoses were poor despite of favorable GCS, H and H-L were common findings. SAH and IVH were also common. The poor prognosis was induced by secondary systemic complications, such as pneumonia and meningitis, etc.