In cerebral aneurysm surgery, an effort to reduce an operative risk, furthermore, must be continued generously. With that purpose, the possibility that various complications occur must be assumed always.
  Perforating artery injuries can occur due to failure to recognize clip co-occlusion, or kinking at its origin, or pulling it up, and so on. Therefore, it is very important for the operator to observe well and to adequately exfoliate in order to prevent these troubles. A technique where by the dissecting manipulation can be completed safely is also needed.
  Clip insertion in a free direction and the delicate adjustment of the clipping line are necessary to avoid a stenosis of the a parent artery or branching artery by clipping. At the same time, it is important to obtain sufficient mobility of the aneurysm and the branching arteries. This mobility leads to both good visibility and safe operation. A large surgical field realizes a free visual axis and an adequate manipulation angle. Thorough dissection without compromise leads to a safe and successful outcome. It is also important to preserve all veins as much as possible by denuding to avoid venous infarction or hemorrhage.
  In a complicated aneurysm such as a large sized or sclerotic aneurysm, a conbined procedure including an arterial bypass should be selected. In this type of bypass combined surgery, intraoperative measurement of the arterial blood flow using a transit-time flowmeter will be very useful.

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  Embolization of cerebral aneurysms is generally the less invasive treatment option. However, hemorrhagic complications such as intra-procedural rupture and ischemic complications such as thrombosis and embolism may occur with low incidence due to the fragility of the aneurysmal wall and the thrombogenicity generated by catheters and coils. Small aneurysms less than 3 mm in size, large aneurysms, wide-neck aneurysm, stent assisted embolization and acutely ruptured aneurysmal embolization are all at high risk for complication. To prevent complications in such cases, the perioperative administration of an appropriate anti-thrombotic medication and an effective working projection are mandatory. For intra-operative rupture, hemostasis with balloon inflation in front of the aneurysm and continuous coil placement are essential. Subsequent craniotomy might also be considered in some cases. For thrombosis or embolism, intensive anti-thrombotic medication is also mandatory. Subsequent endovascular recanalization should be considered for some cases.

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  In the treatment of cerebral aneurysms, a combination of open and endovascular surgeries may be necessary when simple clipping or coiling are difficult. The authors retrospectively analyzed such patients to clarify the current status and issues to be overcome. Between 2003 and 2012, clipping was selected as the first choice until 2007 and coiling thereafter. Five representative cases with the combination therapy are presented. Case 1 : A giant internal carotid artery (IC) aneurysm at the cavernous portion was treated with a high flow bypass and parent artery occlusion, based on the finding of the preoperative balloon test occlusion which revealed severe reduction of cerebral blood flow upon IC occlusion. Case 2 : A ruptured vertebral artery dissection involving the posterior inferior cerebellar artery (PICA) was treated with the occipital artery (OA) -PICA bypass followed by internal trapping of the dissection and the parent artery with a coil. Wallenberg syndrome developed, but the patient became independent. Case 3 : A giant basilar artery-superior cerebellar artery (SCA) aneurysm was treated with a superficial temporal artery-SCA bypass followed by coil embolization of the aneurysm sac, because the SCA originated from the dome of the aneurysm. Case 4 : Clipping was intended for so-called kissing aneurysms, comprising IC-posterior communicating artery (Pcom) and anterior choroidal aneurysms ; however, adhesion between the aneurysms and with the Pcom itself was too tight to dissect. After discussion with the endovascular surgeons, the clipping was abandoned and coil embolization was successfully performed one month later. Case 5 : A case of a subarachnoid hemorrhage with IC-PC and basilar tip aneurysms. Coiling was intended for both aneurysms in the acute stage. It was revealed during the coiling procedure for the basilar tip aneurysm that one of the two humps of the aneurysm was difficult to occlude completely. A perforating artery of the basilar tip was shown by microcatheter angiography. The surgical team was consulted and the basilar tip aneurysm was clipped successfully after coiling of the IC-PC aneurysm.
  For aneurysms which are difficult to treat with simple clipping or coiling, a combination of open and endovascular surgeries may play a valuable role after effective communication between the neurosurgeons and endovascular surgeons. There remain certain limitations in terms of completeness of the aneurysm occlusion and perforators which still need to be overcome.

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  The purpose of this study was to introduce our initial experience of using hybrid microsurgery and intravascular surgery for treating complex cerebral aneurysms (ANs) and arteriovenous malformations (AVMs). The hybrid surgery included a single operative intervention of microsurgical partial neck clipping (neck plasty) followed by coil embolization for patients with ANs and strategic intravascular embolization after craniotomy followed by removal for patients with AVMs. Intraoperative microcatheter 3D-angiography, ICG videoangiography, Doppler sonography, and electrophysiological monitoring were all routinely used. Total obliteration of the lesion was achieved in all patients without significant morbidity. The hybrid suite is a useful setup which allowed for an unconstrained combined microsurgical and neuroradiological workflow. Our initial experience introduces hybrid surgery as a safe and more durable treatment option for the management of complex intracranial ANs and AVMs.

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  Arteriovenous malformations (AVMs) show incredible diversity. In Japan, multimodal treatment involving craniotomy, endovascular treatment, and radiotherapy is widely used to leverage the strengths and minimize the weaknesses of each individual treatment method. With the approval of Onyx, a non-adhesive liquid embolic agent, endovascular embolization has come to play an exceedingly important part in AVM treatment. While the curative capacity of embolization alone has markedly increased, embolization is of particular use in an adjuvant role for facilitating bleeding control during craniotomy for resection. N-butyl-cyanoacrylate (NBCA) has the major advantage that its concentration can be freely adjusted, leading to a central role in the embolization of high-flow feeders and targeted embolization for which Onyx is less effective. Moreover, the superior curative capacity of craniotomy for resection and the low-invasiveness of stereotactic radiosurgery also play an important part in multimodal therapy. In the present paper, we compare the current state of AVM treatments and ARUBA study findings and discuss the future of AVM treatment.

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  Glioblastoma multiforme (GBM) often infiltrates surrounding tissues, an action which is known as a clinical characteristic of this deadly disease. In contrast, extracranial metastases of GBM rarely occur. Consequently, the underlying mechanisms and prognosis of GBM metastasis remain unclear. In this regard, we here present a case of GBM with pleural metastases and discuss the relevant literature. The patient was a 62-year-old male who was originally diagnosed with GBM in the right temporal lobe and underwent craniotomy for tumor removal. Gross total resection was successfully performed. The patient received postoperative chemoradiotherapy with temozolomide, followed by maintenance chemotherapy with temozolomide alone. He showed a good postoperative course until a small recurrence occurred in the resection cavity at 17 months after the surgery. At 21 months, the patient developed thoracodorsal pain due to a large volume of pleural effusion with pleural masses. An intrathoracic biopsy revealed that the pleural lesions were metastases of the GBM. Simultaneously, intracranial imaging studies indicated tumor spread into the right cavernous sinus. These findings suggest that the GBM may have infiltrated into the cavernous sinus via the dura surrounding the cavernous sinus adjacent to the resection cavity and metastasized hematogenously to the pleural cavity.

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