The purpose of this study is to find the better form of early treatment for patients with aneurysmal subarachnoid haemorrhage (SAH). Since endovascular coil embolization was introduced as the early treatment of SAH, 325 SAH patients underwent angiography and 280 patients were treated at an acute stage using either surgical clip application or endovascular coil embolization (1997 onwards, Group B). We retrospectively analyzed the therapeutic decision-making process in these 280 cases and compared its outcome with that of 299 consecutive cases treated before the introduction of coil embolization (1990〜1996, Group A). Of the 280 cases, 177 cases (63%) were treated with surgical clip application and 103 cases (37%) with endovascular coil embolization. In the patients with poor SAH grades (Hunt & Kosnik [H & K] grade 4〜5), high age (≥70 yr), posterior circulation aneurysm and multiple aneurysms, endovascular coil embolization was preferentially chosen. The percentage of the patients with occluded aneurysm at the acute stage significantly increased from 54% (Group B) to 78% (Group A), from 42% to 76% and from 50% to 81% in the cases of H & K Grade 4〜5, high age and basilar bifurcation aneurysm, respectively. As a result, the percentage of the cases with favourable outcome (Glasgow Outcome Scale score 1 or 2 at discharge) significantly increased. Early rebleeding occurred in two cases that had been treated with endovascular coil embolization. Although endovascular coil embolization has the advantage of being less invasive to the brain, its treatment completeness is considered inferior to surgical intervention. We should choose treatment strategy for aneurysm on a case-by-case basis, depending on factors including the neurological conditions, patient age and general conditions as well as the aneurysm location, size and configuration.

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The utility and limit of coil embolization as a therapeutic first choice for 117 of 122 (96%) patients with ruptured cerebral aneurysms in the acute phase for last five years are discussed. Patients (41%) older than 70-years-old, cases of ACA aneurysms and MCA aneurysms (39% and 25%, respectively) were included as subjects of the present study. The incidence of complications during coil embolization, symptomatic vasospasm and normal pressure hydrocephalus were low and outcomes at discharge were good, and there is no inferiority in comparison with results of RESAT2002 or other institutions. The low-invasive merit of coil embolization was shown in the shortened length of hospitalization in particular. The utility of coil embolization for ACA aneurysms became clear as well as for ICA, V-B aneurysms. Craniotomy hematoma evacuation after coil embolization was performed in patients with intracerebral hemorrhage if necessary, an increase of hematoma during coil embolization was present in some cases of MCA aneurysm, and these were not necessarily excellent results. Additional coil embolization for recanalization was performed in 15 patients (12.8%). Postoperative periodic image follow-up is essential, and careful image follow-up and additional embolization when recanalization is shown in aneurysms having a neck remnant or body filling, or intracerebral hemorrhage in particular, is an important point of rebleeding prevention.

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The removal of subarachnoid clot has been thought to be effective for prevention of cerebral vasospasm. However, it is suggested that the incidence of cerebral vasospasm is not high in the cases whose ruptured cerebral aneurysms are obliterated using coils without clot removal. The effect of subarachnoid clot removal on the occurrence of cerebral vasospasm and the different incidence of cerebral vasospasm between in clip cases and in coil cases are reviewed. Surgical clot removal during early aneurysm surgery had failed to show satisfactory preventive effect for vasospasm, and the cumulative incidence of symptomatic vasospasm in these trials was 29%. On the other hand, the cumulative incidence of cerebral vasospasm in coil cases was 20%. The comparative studies of the incidence of vasospasm between in coil cases and in clipping cases also showed a less incidence of symptomatic vasospasm. One reason of higher incidence of vasospasm in clip cases are thought to be attributable to delayed wash-out of subarachnoid clot by cerebrospinal fluid because of destruction of physiological structure in subarachnoid space. Another reason might be damage of brain and cerebral vessels during clipping surgery. Considering these factors, use of fibrinolytic drugs, maintaining physiological cerebrospinal circulation, and less invasive surgery are essential for prevention of vasospasm in clip cases. In coil cases, intrathecal infusion of fibrinolytic drugs through lumbar drainage seems promising method.

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This is a review article of the current status of aneurismal treatment in Japan. In the treatment of acutely ruptured aneurysms, the ISAT and the CARAT studies have a strong impact and the treatment modality has new changed from clipping to endovascular coil treatment. With an unruptured aneurysms, coil treatment still has a problem in the long-term rupture prevention. The present indication is for aneurysms larger than 5 to 7mm and situated in particular anatomical locations where the clipping appears to be difficult, such as paraclinoidal, cavernous and vertebral basilar territory. New devices such as the hydro-coil, drug-eluting coil, liquid materials, intracranial stent and covered stent were also reviewd.

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Clipping surgery is one of the most common and essential procedures for neurosurgeons. With the recent advances in the intravascular procedure, opportunities to use clipping surgery have decreased. In such a situation, we need to have an effective clipping procedure training system for young neurosurgeons. Basically of course, to become an expert surgeon, one must have a strong desire to become an expert surgeon. One needs to learn from each patient. One needs to observe expert-level surgery as many as possible. In this paper, we describe several points which we conduct as routine procedures for training young neurosurgeons. 1) For each case, case conferences are held which include pre-preoperative, preoperative and post-operative conferences. In the pre-preoperataive conference, detailed surgical procedures are presented by a resident including the clipping procedure: which clip (s) will be used, how it is (or they are) applied, etc. In the pre-operative conference, the detailed procedure is presented by showing surgical procedures and the expected operative drawing. In the postoperative conference, the surgery was summarized by showing edited video. 2) The surgical procedure and clipping procedure, are simulated in detail using 3D neuroimagings. 3) Operative videos and operating records of all the cases for more than the last 20 years have been stored, and they can be reviewed. 4) An operating microscope with 2 stereroscopic-assistant scopes is used. With this microscopic system, an assistant can actively attend a surgery, Alternatively a superviser can assist a young surgeon through the assistant scope. 5) In the laboratory, two operating microscopes are set-up. Microsurgical procedures can be exercised at any time. 6) Case conference is regularly held focusing especially on surgical complications and attended by all doctors working at affiliated hospitals as well as the University Hospital.

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The purpose of this retrospective study was to evaluate the results of two treatment options, endovascular coil embolization and surgical neck clipping, for ruptured intracranial aneurysms in aged patients (over 70 years old) where the treatment began within 72 hours after the ictus. During the last 11 years, 46 patients were treated with coil embolization (n=27) or clipping (n=19) in our hospital. Ruptured dissecting aneurysms and giant aneurysms were excluded in this study. Coil embolization was preferably chosen when the patient was over 75 years old, with high neurological grade, and the aneurysm was located in the posterior circulation. Clinical outcomes were evaluated using the Glasgow Outcome Scale at discharge. In the coil embolization group, 11 of 14 (78.6%) patients with Hunt and Kosnik grade I-III showed good recovery (GR) or moderately disabled (MD). In the clipping group, 6 of 13 (46.2%) patients with grade I-III showed GR or MD. However, there was no favorable outcome in patients with grade IV in either group. After the treatment, incidences of vasospasm related cerebral infarction and shunt dependent hydrocephalus were not significantly different between the two groups. The incidence of pneumonia during the hospitalization was higher in grade III and IV patients compared with grade I and II patients. In conclusion, elderly patients over 70 years old suffering from intracranial ruptured aneurysm with a Hunt and Kosnik grade I-III can be treated successfully using coil embolization or clipping. However, treatment indication should be carefully determined in grade IV patients.

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The authors report two cases of rotational vertebrobasilar insufficiency (VBI). Both patients presented with vertigo and syncope attacks at the time of head rotation. They were diagnosed with rotational VBI by dynamic angiography performed with their upper body elevated and head rotated. In both patients, the vertebral arteries were being compressed by osteophytes of the cervical spine resulting in stenosis and occlusion of the artery thereby manifesting the associated symptoms. The patients underwent anterior fusion of the cervical vertebra as well as removal of the offending osteophytes, and their symptoms disappeared. Rotational VBI should be suspected in patients with vertigo and syncope whose vertebral artery is hypoplastic or occuluded on one side. Anterior fusion of the cervical vertebra to limit rotation of the cervical spine and occlusion of the VA is an effective treatment for rotational VBI.

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