Following recent advances in intravascular surgery for aneurysms, it seems valuable to summarize the current status of intravascular and surgical treatments in patients with subarachnoid hemorrhage as well as cooperative strategies for both treatments. A total of 573 cases with subarachnoid hemorrhage in the past five years was retrospectively analyzed. Principle strategy during this period was to consider clipping first in the acute stage whenever possible, and coiling was considered first in cases with basilar tip and carotid cave aneurysms, vertebrobasilar dissections, higher patient age and poor general conditions. Independent daily activity with or without neurological deficits at discharge was achieved in 52.5% of all cases including non-surgical cases, and in 85.4% of clipped and 71.4% of coiled cases. Cooperative surgical and intravascular techniques were necessary and effective in preoperative test occlusion, intraoperative angiography, suction decompression, parent artery occlusion with bypass surgery, multiple aneurysms, and others. Since overall outcome of subarachnoid hemorrhage is not satisfactory, further advancement is desired in each of the surgical and intravascular techniques and their cooperative strategies.

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Stroke is the most common complication in those patients with symptomatic coronary artery disease requiring coronary artery bypass grafting (CABG). Severe stenosis of the internal carotid artery (ICA) may induce stroke following intraoperative hypotension, even if bypass surgery is performed with off-pump coronary artery bypass (OPCAB). Carotid artery stent placement is beneficial, however, this technique displays disadvantages of postprocedural hypotension attributable to stretching of the carotid sinus, which may exacerbate severe myocardial ischemia. We report four cases of ICA stenosis treated initially with intentional partial PTA (adjuvant PTA) in an attempt to reduce the risk of post-procedural stroke following CABG. Subsequently, CABG was conducted as quickly as possible to improve cardiac function, followed by radical CEA after recovery from the invasive CABG. Patients, all males aged from 71 to 79 years (mean 73.3), were admitted with stable angina pectoris and diagnosed with coronary disease necessitating early treatment with CABG. Subsequently, ICA stenosis was detected by preoperative screening. Cerebral angiography revealed severe ICA stenosis and near-occlusion in three patients; mean stenosis rate was 93.0% (range 77-99%). Adjuvant PTA was performed successfully with a low profile (3.0-3.5 mm) balloon catheter employing a distal protection system with no incidence of hypotension or myocardial ischemia. Following PTA, mean stenosis rate was improved from 93.0% to 58.8% (range 50-70%). All patients underwent OPCAB at mean 7.0 days post PTA and with CEA at mean 10.8 weeks post PTA; neither major stroke nor myocardial infarction occurred. In a series of the periprocedural period, the permanent morbidity and mortality rate was 0%. In the patient priory to CABG associated with severe ICA stenosis, a sequential regime comprised of "adjuvant PTA→CABG→CEA" is useful for prevention of periprocedural ischemic complications.

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We discuss an optimal therapy for jugular foramen schwannomas (JFSs) designed to minimize the risk of neurological deficit, based on tumor location, shape and size. We treated fourteen patients with JFSs in this study. They were classified into two types according to tumor location; intradural (ID) and intra/extradural (ID/ED). In cases without brainstem compression, the patient was treated by gamma knife radiosurgery (GKRS). Conversely, where compression was evident, surgery was initially performed. In compressed ID cases, the intracisternal portion was resected using a lateral suboccipital approach, followed by GKRS for the residual tumor in the JF. In ID/ED cases, the transjugular approach was primarily used, in addition to the transcervical where there was upper cervical extension. While the six symptomatic cases showed little or no post-surgical improvement, the eight asymptomatic cases yielded no posttreatment deficit. These results indicate that a combined treatment strategy chosen according to tumor shape, location and size is a very effective treatment modality for JFSs.

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The authors present a new operative positioning for the dorsal brain stem lesions, and show the merits of this simple positioning. The patient, who has the midline dorsal brain stem lesions (2 cavernous angiomas, hemangioblastoma, Chiari malformation) lies in the lateral park-bench position and the upper half is elevated in 30 degrees, with the head tilted to the right in 15 degree and the neck flexed anteriorly as possible. A Mayfield' three popints fixation instrument is used as usual craniotomy. This "park-bench tilting position" is achived instantly without special instrumentations. And this operative positioning almost never makes the risks for air embolism. Another advantage for the operator with this positioning, the surgeon can achieve all courses of microsurgical procedure for dorsal brain stem lesions in the sitting position by himself.

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We report a case of idiopathic thoracic spinal cord herniation treated successfully with Gore-Tex^[○!R] Patch. A 49-year-old man who presented with a progressing spastic paraparesis over 6 years was diagnosed as idiopathic spinal cord herniation. Magnetic resonance imaging of the thoracic spinal canal demonstrated C-shaped anterior kinking and transdural herniation of spinal cord at the level Th_<4/5>. His symptoms deteriorated gradually in spite of the surgery in a private hospital and he underwent surgery in our institution. Intraoperative findings demonstrated spinal cord herniated into the cavity between the duplicated dura mater through the defected inner dura. The herniated part of the spinal cord was reduced and the dural defect was repaired with Gore-Tex^[○!R] membrane. Spastic paraparesis disappeared a week after surgery. The long-term outcome of surgery was excellent over 7 years. We review the reports of 84 cases and summarized the clinical features, radiological diagnosis, and treatment.

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We report a rare case of a ruptured de novo aneurysm induced by Aron Alpha^[○!R] (ethyl 2-cyanoacrylate). A 39-year-old woman, treated with hemodialysis for chronic glomerulonephritis 2 years prior to this hospitalization, underwent microvascular decompression for left hemifacial spasm at another hospital. The offending vessel was the left posterior inferior cerebellar artery (PICA). The Left vertebral artery (VA) was mobilized and affixed to the dura mater with Aron Alpha^[○!R] to remove pressure from the PICA to the root exit zone of the facial nerve. The left VA was found to be intact at the time of the operation. One year later, the patient suffered subarachnoid hemorrhage (SAH) caused by rupture of a newly-developed aneurysm of the left VA. Endovascular parent artery occlusion was performed using Guglielmi detachable coils. Although cyanoacrylate adhesives have been used in microvascular decompression for transposition of the offending vessel, several experimental and clinical studies reported vascular toxicity of these substances. To prevent SAH after microvascular decompression, Aron Alpha^[○!R] should be avoided, if possible, for transposition of offending vessels in the microvascular decompression, and follow-up magnetic resonance angiography is recommended to rule out development of an aneurysm, although the incidence of this sequela is unknown.

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We report a rare case of chondroblastoma arising from the frontal bone of the cranium. The patient, a 12-year-old boy, was admitted to our hospital suffering from generalized seizure. Initial examination revealed no neurological deficits, but CT and MRI revealed a mass lesion involving the left frontal bone and extending to the intracramal space The tumor was resected successfully, and diagnosed histologically as chondroblastoma on the basis of the characteristic features, including a chondroid matrix that was positive for S-100 protein and multinucleated giant cells lying among small round chondroblasts. Chondroblastoma is a rare bone tumor mainly affecting the long bones of young individuals. Its occurrence in the skull is uncommon, but most such cases have been reported to arise in the temporal bone or skull base, which develop through a process of enchondral ossification. Chondroblastoma arising in convex cranial bones, which develop through a process of intramembranous ossification, is extremely rare.

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