According to the results of the Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial, warfarin is not recommended because of safety concerns, while aspirin is not enough for secondary stroke prevention in patients with symptomatic intracranial artery stenosis (IAS). The results of the Trial of Cilostazol in Symptomatic Intracranial Arterial Stenosis (TOSS) trial showed that a combination of aspirin and cilostazol inhibited the progression of IAS, although the effect on stroke prevention remains uncertain. A randomized controlled trial to compare aspirin plus cilostazol and aspirin alone (Cilostazol Aspirin Therapy against Recurrent Stroke with Intracranial Artery Stenosis; CATHARSIS) trial is ongoing in Japanese patients with symptomatic IAS. Inclusion criteria for the CATHARSIS trial are patients with ischemic stroke within two weeks to six months of onset, who are associated with 50% or more stenosis in the supraclinoid internal carotid artery, M1 portion of the middle cerebral artery, or the basilar artery on magnetic resonance angiography (MRA). Recruited patients are randomized to be allocated into either a group on aspirin (100mg daily) alone or aspirin (100mg daily) plus cilostazol (200mg daily), who are followed up for at least two years. Primary endpoint is the progression of intracranial arteries on MRA. Secondary endpoints are ischemic events including ischemic stroke and hemorrhagic events including hemorrhagic stroke as well as silent brain infarcts and activity of daily living. The CATHARSIS trial may provide useful information to establish the best medical treatment and for future randomized trials to compare medical treatment and intravascular intervention in IAS patients.

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For acute ischemic stroke patients, oral aspirin is highly recommended. In Japanese guidelines, intravenous ozagrel and argatrobane are other choices. Although intravenous heparin is often used for acute stroke patients, its efficacy has not been established. For patients with chronic noncardioembolic ischemic stroke, antiplatelet therapy rather than anticoagulation is recommended to reduce the risk of recurrent stroke and other cardiovascular events. The choice of antiplatelet agents differs among guidelines from Japan, United States, and Europe. Among agents which are in commercial use in Japan, aspirin, clopidogrel, and cilostazol are recommended as the major choices. The combination of aspirin and clopidogrel is not routinely recommended. Recently, observational studies from the Bleeding with Antithrombotic Therapy (BAT) Study group were published which determined the characteristics of bleeding complications in Japanese antithrombotic users.

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Objective: Atherosclerotic intracranial stenosis is considered one of the major causes of ischemic stroke. We analyzed cerebral blood flow (CBF) and plaque characteristics in atherosclerotic intracranial internal carotid stenosis (iICS) patients to evaluate the risk of ischemic stroke. Methods: Since November 2003, 26 lesions in 25 patients were treated at our institution. All patients underwent plaque characterization using MRI and CBF evaluation using SPECT. Results: Only one lesion caused severe hemodynamic insufficiency and two patients had vulnerable plaque in their stenotic segments. Tandem lesions were existent in 9 lesions (35%) and contralateral lesions were existent in 11 patients (44%). Conclusion: Based on the CBF and plaque imaging results, the risk of ischemic stroke due to iICS itself is not thought to be so high as previously reported.

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Recently, intracranial artery stenosis has attracted more attention as a cause of atherothrombotic cerebral infarction than before due to the development of imaging technology such as MR angiography and 3D CT angiography. The frequency of intracranial stenosis is no less than extracranial lesions such as cervical carotid stenosis, and the rate of stroke recurrence between extra- and intracranial stenosis is almost equal. Based on the development of neuroendovascular therapy, over the last two decades, percutaneous transluminal angioplasty and stent placement have become feasible as treatment options for lesions of intracranial arteries. Several clinical trials have been published with favorable results, while novel specific devices have been developed for intracranial use. In Japan, reports of cases and series have been increasing despite being an off-label treatment yet to receive government approval. A consensus on indication, standard procedure, and perioperative management has been authorized between specialists. These results highlight the need for controlled clinical trials to determine the value of PTA/stent placement for intracranial stenosis.

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This study reports a unique case of a severely obese patient who was treated with intrathecal baclofen therapy (ITB) due to the failure of the standard technique owing to severe obesity and post-traumatic spinal deformity. This 30-year-old man had been suffering from severe spasticity (Ashworth score: 4.06) for 15 years following a spinal cord injury at the C_3 level. Initially, baclofen screening trials were proposed to be conducted in the usual manner; however, the patient was detected to be too obese, with a depth of 90mm from the skin to the subdural space, for the surgents to reach the subarachnoid space percutaneously with normal spinal needles. Furthermore, a 3D-bone CT of his lumbar spine revealed remarkably fused laminae. Therefore, his paravertebral muscles were exposed under local anesthesia, and a spinal drainage catheter was inserted via the inter-laminar space. Subsequent screening trials of baclofen showed good relief of spasticity. An ITB pump was then implanted successfully via a paramedian approach, and spasticity was reduced successfully (Ashworth score: 2.5). Some patients with spinal cord injury are severely obese and possess spinal deformity. For such patients, the standard ITB procedure would usually fail. Present method offers an alternative to this but a 3D-bone CT of the lumbar spine is mandatory before surgery.

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In spontaneous cerebrospinal fluid hypovolemia (SCH), the conservative treatment is resting the patient in bed followed by intravenous hydration for several weeks. However, in cases where improvements are not established, epidural self-blood patch (EBP) therapy is then resorted. We experienced a case of SCH, who suffered symptomatic relapse five days after initial treatment with EBP therapy. The condition of the patient eventually exacerbated to coma, resulting in chronic subdural hematoma (CSH). As the coma was well managed by a conservative therapy, the condition of the patient improved when we repeated the EBP therapy followed by burr-hole irrigation for CSH two weeks later. As a sudden change in the intracranial pressure could induce acute aggravation of CSH and impairment of consciousness with acute recurrence of cerebrospinal fluid leakage, SCH patients treated by EPB therapy have to be monitored consistently. Due attention must be paid to CSH induced by spinal tap during diagnosis and possible acute recurrence after the first successful EBP therapy.

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We present a surgical case with a giant serpentine aneurysm of the left middle cerebral artery. A 56-year-old man was transferred to our hospital due to progressive motor paresis of the right side and difficulty speaking. Neuro-radiological examinations revealed a giant mass lesion in the left peri-sylvian region, which was 65mm in size and was diagnosed as a giant serpentine or thrombosed aneurysm. The aneurysm was incised through a left fronto-temporal craniotomy with the assistance of a preparative superficial temporal artery-middle cerebral artery (STA-MCA) bypass. While evacuating the thrombi, branches of the MCA had to be trapped due to premature bleeding from the aneurysm. After the trapping, motor evoked potentials (MEPs) and somatosensory evoked potentials (SEPs) became flat. The changes hastend us to a quick evacuation of the thrombi and a relocation of the temporary clips to restore MCA blood flow. The aneurysm, which was caused by diseased vasular wall, was finally trapped and excised. Postoperatively, the patient recovered from both the motor paresis and aphasia. Giant serpentine aneurysms are difficult to treat. However, aggressive treatment is often required because of the progressive deterioration of the patient's symptoms. Intraoperative monitoring of MEP and SEP may be helpful to prevent ischemic complications.

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