There are 2 surgical approaches to hypertensive intracerebral hemerrhage ; open craniotomy and stereotactic aspiration surgery (SAS) and neurosurgeons should be familiar with both procedures. In open craniotomy, the transsylvian or transcortical approach can be used when the patient is in a very acute stage and hemostasis is required to provide a clear field of vision under the microscope. The incidence of postoperative seizure is lower in the transsylvian than the transcortical approach. SAS is the less invasive of the 2 procedures. It can be carried out under local anesthesia, the operative time is short and the required instrumentation is relatively simple. Deep-seated hematomas (thalamic or pontine hemorrhage) can also be aspirated using SAS and the procedure may be appropriate for elderly or high-risk patients. Positioning of the needle for aspiration can be achieved with ultrasound-guided, CT-guided (with or without a localizing frame), or MRI-guided stereotaxy. The CT-guided method is most commonly employed. Various mechanical devices have been tested in attempts to improve clot removal, e. g. the Archimedes screw ; a coaxial double cannula, the ultrasonic aspirator, and the water jet. Before surgery, the presence of vascular lesions (aneurysms, arteriovenous malformations (AVM), dural AVMs, cryptic AVMs, cavernous hemangiomas, and cerebral amyloid angiopathy) should be ruled out by cerebral angiography, MRA (Magnetic Resonance Angiography) or 3 D-CTA (3 dimensional CT angiography).SAS should not be performed earlier than at least 6 hours after onset. To avoid intraoperative bleeding, not more than 70% of the clot should be aspirated initially. Blood pressure must be carefully controlled during the aspiration procedure. The residual hematoma should be drained out by urokinase infusion within 3 days of the initial aspiration. SAS may be indicated for patients with putaminal hemorrhage where the hematoma volume is greater than 30ml, for cerebellar hemorrhage patients with a hematoma volume greater than 15ml, for thalamic hemorrhage patients with a hematoma volume greater than 10ml and for subcortical hemorrhage patients with a hematoma volume greater than 20ml . The role of SAS in patients with pontine hemorrhages remains to be determined.

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One of the major concerns of carotid endarterecomy (CEA) is to protect the brain from ischemic insult caused by cross-clamping of the internal carotid artery (ICA). The most effective way is to maintain carotid flow during surgical procedures. We have introduced a newly devised shunt system, T-shaped silicone shunt tubes and clamping devices. The tube has enough pliability and length to be used in a looped or U-shaped mode and forms a T-shape with a side arm available for monitoring blood pressure in the shunt system. Clamping devices, modified Sugita ring clips for the distal side and bulldog clamps for the proximal side, make it possible to hold the tube by a simple maneuver and to minimize the intimal damage. Using this shunt system 170 CEAs were performed, and mortality and morbidity were 0% and 2.4%, respectively. We have demonstrated CEA can be safely and easily performed with a routine application of our shunt system.

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To standardize the care and management of patients with severe head injury may reduce inappropriate care and improve patient outcomes. The optimum guidelines also may reduce the cost of medical care and enhance quality of the management. Recently 2 major sets of guidelines were presented using a different approach. One from the Brain Trauma Foundation of the United State in 1995 and the other from the European Brain Injury Consortium in 1997. The former was developed by evaluating the scientific evidence (evidence-based guideline) and the latter was based on the expert opinion and committee consensus (consensus-based guideline). The major topics of these guidelines are trauma care system, prehospital care and ICU managements, which are deemed to have an impact on outcomes of patients with Glasgow Coma Scale (GCS) score of 8 or less in adults. Despite the contrasting methods used to develop these guidelines, they are nearly the same in essence. In this article, each topics of both guidelines are generally reviewed. Our updating protocol for the management of severe head injury including hypothermia therapy and the preliminary result are described. In addition, controversies on management guidelines are also discussed.

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In recent large randomized trials performed in North America and Europe, the beneficial effects and guidelines of carotid endarterectomy (CEA) have been reconfirmed for symptomatic and asymptomatic patients with highgrade carotid artery stenosis. These studies also demonstrate that successful results of CEA are dependent upon surgeons having perioperative morbidity and mortality rates lower than 6% for symptomatic stenosis and 3% for asymptomatic stenosis. Here we report basic knowledge of atherosclerotic carotid artery disease and standard techniques of CEA. In each process of CEA, including arterial preparation, removal of atheroma plaque and suture of arteriotomy, one must know some techniques to perform surgical procedures with minimum complications. In Japan, this disease is not so common, but the number of patients undergoing CEA are increasing year by year. We also review the somerecent clinical data and discuss about the existing state and problems of CEA in Japan.

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Background and introduction ; Recently, aspiration of hematoma became a main method of surgical treatment for intracerebral hemorrhage. However, it was carried out without gross observation (blind surgery). In this paper, details of an echo-guide aspiration and an aspiration with neuroendoscopy were mentioned. The operative area was observed directly or indirectly in these methods. Echo-guide aspiration ; Target point in the hematoma was decided on echo images without frame of CTstereotactic instrument and the progress of aspiration was directly observed. The residual hematoma after aspiration was observed on echo images. In this method, average removal rate with aspiration was 80%. CT-guide aspiration with neuroendoscopy ; At the first, target point of the puncture in hematoma was decided with a stereotactic CT and an endoscope was inserted inside of a probe of CT stereotactic instrument. Aspiration and irrigation were performed under endoscopic observation and small bleeding site was able to be controlled by a bipolar coagulator through the main channel of endoscope. Average removal rate with aspiration was 85%. Conclusion ; These methods of surgical treatment were useful and expected to become most important methods of the first choice.

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We report our experiences with internal carotid artery (ICA) aneurysm arising near the dural ring in 13 patients (15 aneurysms) treated by endosaccular embolization using Guglielmi detachable coil (GDC). Patients ranged in age from 44 to 79 years old (average 58 years) and were all female except one male. Fourteen aneurysms were asymptomatic and 1 presented with subarachnoid hemorrhage (Hunt & Kosnik grade IV). The aneurysm was less than 5 mm in diameter in 5, between 5 mm and 12 mm in 7, more than 12 mm in 3. In GDC treatment, it was not always easy to navigate the microcatheter into the aneurysm due to the curve of the carotid siphon, position of the neck, and the projection of the dome of the aneurysm. In these instances, preshaping the tip of the catheter with steam was very helpful. During the insertion of GDC, remodelling of the ICA was performed using the assist balloon in most cases. Total obliteration was obtained in 10, and more than 95% obliteration was possible in 4 aneuryms. In one aneurysm, stable placement of the microcatheter was impossible and embolization was abandoned. Complication was encountered only in this left-handed patient, who developed a temporary motor aphasia and left arm weakness due to a small cerebral infarction in the right frontal lobe. A possible cause of this event was ischemia due to prolonged manipulation of microcatheters, and repeated inflation and deflation of the assistant balloon in the ICA with poor collaterals. Remodelling technique seemed to be extremely useful but should be carefully applied. In summary, endosaccular embolization may be considered as a less invasive alternative for this aneurysm, considering the relative difficulty in surgical clipping due to its complex anatomical location.

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A rare case of the epidermoid tumor in the skull is presented here. A 23-year-old woman was admitted to our hospital for examination of unconsciousness attack. Skull X-ray showed a bone defect with sclerotic margin in the left parietal skull. CT showed a low density mass lesion with rim-enhancement. Bone density CT and 3-dimensional CT using helical CT scan were useful for detecting the osteolytic lesion. MRI showed a hypo-intensity area on T1-weighted image and hyper-intensity area on T2-weighted image. On bone scintigram, only the margin of the tumor was stained as a hot area. From these findings, this tumor was diagnosed as epidermoid. We discussed the clinical features and radiological characteristics of the epidermoid in the skull.

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We report a case of a 67-year-old man with sudden onset of right hemiplagia and total aphasia. Left common carotid angiography showed complete occlusion of the cervical internal carotid artery (ICA) near the bifurcation and the ipsilateral middle cerebral artery (MCA) at the M1 segment. The occluded site of the cervical ICA was considered to be a short thrombus judging from the staining in the petrous ICA via the opthalmic artery. A guiding catheter was able to pass through the occluded site of the cervical ICA over a guide wire (0.035 inch, angle type) and intracranial angioplasty was performed through the guiding catheter, enabling an early restoration of the cerebral blood flow. The patient improved after the procedure. Severe narrowing of the cervical ICA remained, and carotid endarterectomy (CEA) was performed. He had no recurrence, and the revascularization of the cervical ICA and MCA at M 1 segment remained after 1.5 years of post-treatment. We recommend a combination of the endovascular and surgical approaches for occlusion of the cervical ICA and the ipsilateral intracranial main trunk.

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