As part of an ongoing series, 100 patients with Cushing's disease underwent transsphenoidal operations. Pituitary adenomas were confirmed in 93 patients, and initial remission was achieved in 86 (92%) of them. Hypercortisolemia was not corrected in 7 patients, and in 4 this was due to invasive adenomas. These patients were subjected to irradiation, medical treatment, or both after operation. Only 7 of the 100 patients had no pituitary adenoma found at operation, and they obtained no clinical remission even after partial or subtotal hypophysectomy. Follow-up review, with an emphasis on endocrinological studies, was performed on these patients for a mean period of 38 months. Seventy-eight patients were in long term remission after operation and had restoration of noncorticotropic hormone secretion as well as pituitary-adrenal function. Recurrence was noted in 8 patients after 19 to 82 months in remission. In all of these patients, pituitary adenomas were verified by reoperation and no case of corticotrophic cell hyperplasia was noted. We conclude that late recurrence of Cushing's disease may occur after adenoma removal and is due to the regrowth of adenoma cells left behind in the peritumoral tissue at the first operation. In view of the overall remission rate, transsphenoidal adenomectomy is considered a highly effective treatment for Cushing's disease.

✓ Nontraumatic subdural hematoma following disseminated intravascular coagulation (DIC) due to advanced cancer was encountered in four patients. It is suggested that DIC plays an important role in the formation of subdural hematoma in cancer patients.

We report a case of multiple communicating intradural cystic lesions. Magnetic resonance imaging did not demonstrate the lesions. Neuroradiological diagnosis of the intradural arachnoid cysts was made from myelography and myelo-computed tomography using both lumbar and cervical punctures. These procedures give us useful information about flow dynamics in the spinal subarachnoid space.

We report a very rare case of a ruptured intracranial anterior spinal artery (ASA) aneurysm. A 66-year-old man presented with gradually deteriorating occipitalgia and mild conscious disturbance. He had a history of hypercholesteremia and diabetes mellitus. There was no evidence of collagen disease or inflammation reaction in his physical examination and laboratory data. The first computed tomography (CT) scan revealed thick subarachnoid hemorrhage (SAH) in front of the brain stem with a little intraventricular clot. However, the cerebral angiography (CAG) showed no apparent aneurysm other than right vertebral artery (VA) occlusion with collateral circulation. Repeat cerebral angiography gradually disclosed the presence of an ASA aneurysm. Therefore, the ASA aneurysm was clipped through the right lateral suboccipital approach under trans-cranial motor evoked potential (MEP) monitoring on Day 61.The amplitude of MEP did not decrease during the operation. The patient did not neurologically deteriorate after surgery. It is previously reported that spinal artery aneurysm should be treated by direct or endovascular surgery because of the risk of rupture. However, recent reports showed that spinal artery aneurysm sometimes regressed spontaneously if it is not flow related. In this case, because of the right vertebral artery occlusion, the fenestrated ASA received hemodynamic stress by collateral circulation.Ruptured aneurysm of the spinal artery requires precise diagnosis and meticulous handling depending on the individual pathogenesis.

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