Some reports have addressed the use of three-dimensional (3-D) models in simulated clipping of cerebral aneurysms. To report on the effectiveness of these models, for this study, we developed two types of 3-D models for use in clipping simulations and for clarifying angioarchitecture and surgical approaches. The two types of model, one made of acrylic polymer and the other made of hollow silicone, were fabricated with a 3-D printer using data obtained with 3-D digital subtraction angiography (3D-DSA). The hollow silicone model was used for simulated clipping, whereas the acrylic model was used as a tool for clarifying angioarchitecture and surgical approaches. We performed simulated clipping of ce-rebral aneurysms with the two types of 3-D model for 10 patients with 11 cerebral aneurysms. In 6 of the 11 aneurysms, the first clips accorded with the clipping simulations. The remaining 4 aneu-rysms exhibited only slight variation from the simulations. In 1 of the 11 aneurysms, the lengths and shapes of the first clips did not accord with the clipping simulations. The hollow silicone model was effective at aiding in the proper selection and manipulation of the clips. The acrylic model was effective at confirming the surgical approach, aneurysm depth, and backside angioarchitecture. Moreover, the procedures were performed smoothly with a microscope without the need to use the monitor, as it was utilized in a clean field. These two types of 3-D model helped the surgeons gain a clear and intuitive understanding of aneu-rysm and angioarchitecture in three dimensions. As a result, they were highly useful for simulating clip application.

The authors conducted a prospective comparative study on the recurrence rate of chronic subdural hematoma after the use of two different treatment modalities: burr-hole irrigation of the hematoma cavity with (Group A) and without closed-system drainage (Group B). Thirty-eight patients were studied. Patients were assigned to groups sequentially upon admission. There were no significant differences between the two groups for age, sex, preoperative hematoma volume, and density on computed tomographic scan. One patient in Group A (5%) suffered a recurrence as opposed to 6 in Group B (33%). The difference in recurrence rate between the two groups was statistically significant (p < 0.05). The authors conclude that closed-system drainage after burr-hole irrigation reduces the recurrence rate of chronic subdural hematoma.

A water-soluble, novel synthetic compound, AVS ((+/-)-N, N'-propylenedinicotinamide; nicaraven) has no demonstrable vasoactive properties but scavenges hydroxyl radicals in aqueous environmental conditions at neutral pH. Based on the results of preceding experimental and clinical studies showing marked ameliorative effects of AVS on cerebral vasospasm and ischemic brain damage, a multicenter, placebo-controlled double-blind clinical trial was undertaken to verify its beneficial effects on delayed ischemic neurological deficits (DINDs) due to vasospasm and on the overall outcome of patients with subarachnoid hemorrhage (SAH). A total of 162 patients with SAH who had Glasgow Coma Scale scores between 7 and 15 on admission were enrolled in the trial. Drug administration (4 g AVS or 4 g glucose as placebo; infused intravenously for 6-8 hours once a day) was begun within 5 days post-SAH and continued for 10 to 14 days. Intent-to-treat analysis of these patients revealed that the overall incidence of DINDs, which was defined as an exacerbation of impaired consciousness and/or focal neurological deficits, was significantly reduced, by 34.5% (placebo 54.2%, AVS 35.5%; p < 0.05, Mann-Whitney U-test). The Glasgow Outcome Scale (GOS) score at 1 month was significantly improved by AVS (p < 0.05, U-test). At 3 months, the difference in the GOS scores between the groups became marginal on U-tests (p < 0.10), but the percentage of good outcome tended to increase, with a relative increase of 20.3% (AVS 76.3%, placebo 63.4%; p < 0.10, chi-square test), and the cumulative incidence of death was significantly reduced (p < 0.05, log-rank test). No significant adverse reaction attributable to treatment was observed. the usefulness of AVS in therapy for SAH is strongly indicated by the fact that the agent significantly ameliorated DINDs, leading to a marked improvement in the GOS scores at 1 month, as well as a reduction in the cumulative incidence of death by 3 months.

Ultra-early surgical treatment in which associated brain injury is minimized and maximal volume of hematoma is removed shortly after onset with secure hemostasis is expected to be established. We developed a transparent guiding sheath and other surgical instruments for endoscopic surgery and established a novel, ultra-early stage surgical procedure using those instruments. This procedure has the following characteristics: (a) burr hole opening under local anesthesia is possible; (b) a transparent sheath improves the visualization of the surgical field in the parenchyma and the hematoma; (c) free-hand surgery without fixing an endoscope and a sheath to a frame facilitates three-dimensional operation; (d) secure hemostasis by electric coagulation is possible; (e) relatively simple surgical instruments are easy to prepare. We have performed this procedure in 82 patients with intracerebral or intraventricular hemorrhage (44 with putaminal hemorrhage, 12 with thalamic hemorrhage, 8 with subcortical hemorrhage, 8 with cerebellar hemorrhage, 10 with intraventricular hemorrhage). Twenty-four of those patients received our treatment in the ultra-early stage (within 3 hours after onset). The mean duration of surgery was 63 minutes, the mean hematoma reduction rate was 96%, and no peri-operative hemorrhage with deterioration of symptoms and/or signs occurred. Therefore, we believe that endoscopic hematoma evacuation with our surgical procedure is a promising ultra-early stage treatment for intracerebral hemorrhage and that it may improve the long-term prognosis in patents with intracerebral hemorrhage.

18 cases of meningiomas in childhood below the age of 15 years at the onset of symptoms and signs were experienced in our clinic. They were studied as for the incidence, age and sex distributions, symptoms and signs at the onset, tumor locations, histological types, presence of cyst, dural attachments, and prognosis, in comparison with cases in adolescence (18 cases) and in adults (498 cases). Distinctive features in childhood meningiomas were: (1) relatively high incidence in the lateral ventricles (11.1%), (2) high incidence of cyst formation in the tumor (16.7%), and (3) of cases without any dural attachment (12.5%). These features were statistically significant as compared to adult cases (p<0.05). Features 1 and 2 were also true for adolescence cases. It was also revealed that male patients were predominent in childhood and adolescence (M:F= 10:8) in contrast to female predominance in adults (M: F = 1:1.6). The most frequent histological type was sarcomatous type (6 out of 18). It may be of interest that 3 cases of this malignant type have been alive for more than 10 years.