This 12-year-old boy suffered from a progressive gait disturbance. MRI and CT scan displayed a large arteriovenous malformation (AVM) located at the anterior medullo-spinal junction. The main feeder was the left anterior spinal artery. This was fed also by bilateral lateral spinal arteries originating from the vertebral artery and bilateral radicular arteries at the C₃ level. Transoral feeder clipping of the anterior spinal artery was successfully performed. Several technical problems were overcome: prevention of liquorrhea using bone graft, abdominal fatty tissue and spinal drainage, selection of an appropriate clip with a small head, monitoring tolerance of occlusion of the anterior spinal artery with the spinal evoked potentials and with confirmation of respiratory function and movement of the four extremities under reduction of the depth of anesthesia. The patient recovered from the intervention completely.
Six months later the patient underwent a feeder clipping of the lateral spinal artery and radicular artery on the left side using the monitoring method mentioned above. The patient endured the operation without any new deficits. Then left hemiplegia appeared two weeks later and three weeks after that the patient expired due to an intramedullary hemorrhage at the site of AVM.

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The common curative treatment of the intracranial aneurysm is neck clipping. When neck clipping is impossible or incomplete, wrapping or coating is added. But these additional treatments cannot avoid the risk of recurrence or rebleeding. Three cases are reported here, the aneurysms of which ruptured simultaneously with clipping resulting in incomplete clipping, and hemostasis was achieved by coating the aneurysms under systemic hypotension.
Case 1: A 60-year-old femele was admitted to the Department of Neurosurgery, Hiroshima University School of Medicine with a ruptured right internal carotid posterior communicating artery (ICPC) aneurysm. The operation was performed on day 0. In spite of several trials, it was difficult to clip the neck completely because of the anatomical location of the aneurysm. Finally the aneurysm was clipped but it ruptured simultaneously. With the use of a temporary clip proximal to the aneursmal neck, an additional clip was applied to the aneurysm under systemic hypotension, but incomplete clipping was apparent because bleeding continued. As bleeding gradually stopped, the temporary clip was removed, then the aneurysm was coated with Biobond Oxycel. Her postoperative course was uneventful, and she recovered fully. Neither angiograms taken on day 9 nor 27 months after the surgery showed the aneurysm.
Case 2: A 48-year-old female was admitted to the Department of Neurosurgery, Hiroshima University School of Medicine with a ruptured anterior communicating artery aneurysm. The operation was done on day 1. Though the aneurysm was clipped once, it ruptured during the confirmation of the situation of clipping. The bleeding point was the neck of the aneurysm, so another clip was applied to the neck. But bleeding continued, which showed that the neck clipping was incomplete. It was possible to stop bleeding by coating the aneurysm with Biobond Bern sheets under systemic hypotension. The aneurysm disappeared angiographically on day 9. A V-P shunt was added for normal pressure hydrocephalus (NPH) one month after the initial surgery and the patient recovered fully.
Case 3: A 60-year-old female was admitted to Department of Neurosurgery, Hiroshima University School of Medicine with a ruptured left ICPC aneurysm. The operation was performed on day 1. But only incomplete clipping was possible because of anatomical difficulty of clipping. Bleeding from the aneurysm occurred simultaneously with clipping. But is was easy to stop the bleeding by coating the aneurysm with Biobond Oxycel under systemic hypotension. Though a V-P shunt was needed for NPH, the patient recovered fully. The aneurysm could not be found angiographically either on day 9 or 6 months after the initial surgery.
A few theories have been proposed to explain the disappearance of an incompletely clipped aneurysm. Those are thrombosis of the aneurysm, occlusion of the aneurysm by the intimal thickening at the clipped site and the reinforcement of the aneurysmal wall by the granulation surrounding the aneurysm. In the three cases described above, it was additionally suggested that the aneurysm was pressed and collapsed by the coating materials.

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Neck clipping was performed on 835 aneurysms (698 cases) in our institute from April 1976 till December 1985, and postoperative recurrent hemorrhage occured in seven cases (0.8%).
It was presumed that postoperative recurrent hemorrhage was due to the“incomplete clip in four cases and due to the“slipped clip”in three cases. Three aneurysms that were treated by neck clipping combined wiht coating because of the inability to obliterate the neck completely, rebled 24-57 days after the operation. It is doubtful, in those cases, whether the best coating material was selected and whether the aneurysmal portion was covered entirely.
One case was a so called“miss clip”
In three cases, slippage of the tip of the blade was observed at the reoperation. The“slipped clip”was caused by a) selection of an inappropriate clip for a given aneurysm or b) inaccurate clip placement.
As postoperative blood pressure was high in six cases, hypertension might have partially caused the rupture of the residual neck or the slip off of the aneurysm clip.

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During the last 17 years, we have had 15 cases of aneurysmal regrowth or rebleeding after direct surgical treatment. In this paper, we have divided the cases into five groups according to the cause of rebleeding or regrowth, and have discussed some of the problems in each group.
Group 1: Incomplete clipping or wrapping; eight cases
Most of the cases in this group had undergone initial operation more than ten years before, and incomplete obliteration of the aneurysms was attributable largely to immaturity of technical skill. Most of the recent cases had anterior communicating or internal carotid artery aneurysms, the necks of which were unusually broad and did not easily accept a clip or a combination of clips. Based on the length of interval after operation, recurrent hemorrhage was divided into early (5 to 15 days after initial operation) and late (5 to 16 years) rebleeding. Early rebleeding appeared to occur when the“responsible”or“ruptured”bleb escaped clipping. In late rebleeding it was assumed that incompletely clipped necks took some time to develop an aneurysmal sac and eventually to rupture.
Group 2: Mycotic aneurysm; 1 case
Mycotic aneurysms often occur multiply in a single case and, for this reason, four-vessel study is mandatory to prevent recurrent hemorrhage.
Group 3: Traumatic aneurysm; 1 case Two traumatic aneurysms occurred in a single case after operation for a large pericallosal artery aneurysm. Avulsion of small cortical branches from the pericallosal artery during the initial operation was responsible for these aneurysms, which bled soon after the initial operation. Use of an encircling clip should be considered whenever a tear of the arterial wall appears to be large enough to produce a postoperative traumatic aneurysm.
Group 4: Aneurysmal development at a site other than the original; 3 cases We retrospectively and precisely reviewed initial angiograms in this group and discovered that small aneurysms had already been present in the initial angiograms. These aneurysms grew larger and evetually bled after periods of 2 to 11 years. From these experiences we believe that incidental small aneurysms discovered in SAH patients should be clipped, if there is a clippable neck, at the earliest possible chance after the initial operation.
Group 5: Regrowth and rebleeding after complete clipping.; 2 cases
In some rare cases we found that a portion of the aneurysmsmal neck was very thin and this portion also involved the wall of the parent artery. In these cases convetional clipping of the aneurysmal neck dose not always ensure against regrowth or rebleeding of the original aneurysm. Application of an encircling clip or clip placement involving a portion of the parent artery, should be considered in such cases.

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We have had five cases of rebleeding after aneurysm surgery from 1973 to 1985. Three cases were anterior communicating aneurysms, and two were internal carotid aneurysms. The anterior communicating aneurysms were directed backward and the internal carotid aneurysms were large“no neck”aneurysms. Neck clipping was performed in two cases, clipping with coating in two cases and clipping with trapping in one case. Retrospectively, the causes of rebleeding were thought to be the incomplete obliteration of the aneurysmal bud with coating, the incomplete obliteration of the neck behind the anterior communicating artery and the fragility of the aneurysmal wall in the large internal carotid“no neck”aneurysm. It can be concluded that it is important to choose an approach which fully discloses the aneurysmal neck behind the parent artery and select an optimal clip to prevent any part of the neck remaining. And because of wall fragility in large“no neck”aneurysms, we must think not only of clipping but also of trapping with bypass surgery.

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It has been generally believed that neck clipping is the safest and most authentic treatment for cerebral aneurysms. However, aneurysmal necks have various shapes and thicknesses and it is not always possible to get a complete obliteration of the neck.
In the last five years, 216 patients were submitted to direct surgery of the aneurysm and of these, six showed rebleeding or regrowth afterwards.
Pre- and post-operative angiograms, infra operative and postmortem findings were studied in each cases and led to the following conclusions.
(1) Wrapping of the residual neck with muscle or Aron-alfa could not prevent the recurrence.
(2) Local fragility of the arterial wall caused by arteriosclerosis or infection could lead to the recurrence of the aneurysm.
(3) Hypertension just after operation could aggravate aneurysmal regrowth by increasing hemodynamic stress.
(4) Postoperative angiogram should be done in all cases, particularly those of thick and broad neck aneurysms and wrapping aneurysms.

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A retrospective hospital chart and radiograph review was performed of 720 cerebral aneurysm operations between April, 1978, and December, 1985. Of these patients, three cases (0.4%) had rebleeding of non-operated cerebral aneurysms in hospitalization after surgical treatment. In these cases, preoperative angiograms were reviewed after ruptured aneurysms were identified, but we could not determine that the rebleeding aneurysms were the ruptured aneurysms.
It is necessary that we always consider the possibility of multiple cerebral aneurysms. We must examine the shapes of the aneurysms, operative features, and the relation between the locations of the aneurysms and the extent of subarachnoid hemorrhage. When in doubt as to whether the aneurysms is ruptured or not, it is necessary that we sufficiently investigate other aspects of the aneurysms, such as an unusual site.

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The authors report experience with the direct surgery of partially thrombosed giant intracranial aneurysms (PT-GIA) which presented with mass effect without recent subarachnoid hemorrhage. There were three cases which located respectively in the VA-PICA, IC-PCom and MC.
Thrombectomy, aneurysmectomy and neck-clipping are thought to be reasonable operations for these PT-GIA. Intraoperative troubles and management of PT-GIA are described.
The most common and dangerous complication is major vessel occlusion or stenosis induced by slipping of the clip. To prevent these problems, we use the following procedures: (1) The dome of the PT-GIA is opened first and the thrombus is removed piece by piece.(2) Fine thromboendarterectomy of the neck is performed. (3) The CUSA system is very useful for thromboendarterectomy. (4) Finally the neck is clipped safely after the PT-GIA has been converted into a pliable sac.
Such internal decompression of the PT-GIA enables us to identify the surrounding tissue and prevent damage to perforating vessels at neck-clipping.
When the PT-GIA is embedded in the brain stem, only a partial aneurysmectomy should be performed, else the brain may be injured.
Intraoperative aneurysmal rupture, a common trouble can be controlled by short temporary occlusion of the proximal main artery; then the neck can be clipped safely. All three cases showed a satisfactory postoperative course.

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It is nearly impossible to determine whether or not the aneurysm neck of a giant carotidophthalmic aneurysm is located partially in the cavernous portion of the internal carotid artery, prior to the direct approach to the aneurysm. This is particularly true when the aneurysm neck is wider than usual and the extent of the aneurysm neck is not clearly visualized on angiograms.
The case presented here is such a case of a 58 year-old female who developed sudden onset of severe headache and consciousness disturbance. Direct approach to the aneurysm was attempted on the second day of the onset of hemorrhage after exposure of the cervical internal carotid artery ipsilateral to the aneurysm. Fenestrated Sugita clips were repeatedly applied to the wide aneurysmal neck after removal of the anterior clinoid process. However, the clips slipped out after release of interruption of the internal carotid artery at the neck, possibly due to failure of complete clipping of the proximal portion of the aneurysm neck which must have been located in the cavernous sinus. Finally, the surgeon gave up the neck clipping at the acute stage. Neither EC/IC bypass surgery with trapping nor ligation of the internal carotid artery was performed because of the possibility of further unfavorable influence on the ischemic and edematous brain due to subarachnoid hemorrhage. Unfortunately, the patient developed repeated bleeding on the following and 4th days after the operation and died.
The authors concluded that direct neck clipping of a giant carotid-ophthalmic aneurysm would be possible in the cases of unruptured aneurysm (or ruptured aneurysm in the chronic stage) as well as of clear visualization of the relatively narrow aneurysm neck on the angiogram, the proximal portion of which aneurysm neck was located at a site distal to the origin of the ophthalmic artery on the lateral view of the angiogram. In addition, an EC/IC bypass with ligation or trapping of the internal carotid artery should always be planned at the same stage, in case of failure of neck clipping.

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There are two major approaches to a basilar top aneurysm: one is the subtemporal method developed by Drake, and the other is the pterional method developed by Yasargil. In either approach, however, it is hazardous and difficult to approach a basilar top aneurysm with megadolichobasilar anomaly because strong retraction of brain, nerve and vessel is required.
A case of a ruptured basilar top aneurysm with megadolichobasilar anomaly successfully treated directly through the third ventricle is reported.
A 62-year-old woman was admitted with consciousness disturbance.
A plain CT scan on admission demonstrated massive and diffuse subarachnoid hemorrhage and a clot in the third ventricle.
The left vertebral angiography demonstrated a 5×5mm basilar top aneurysm with megadolichobasilar anomaly 24mm distant from the dorsum sellae.
The aneurysm was considered to be inaccessible by conventional approaches because of its high position. Therefore, we applied a new approach, described below.
The operation was performed two days after the onset of symptoms, using a bifrontal craniotomy. Dissecting the interhemispheric fissure, we approached the third ventricle via the lamina terminalis. Evacuating the clot in the third ventricle, the basilar top aneurysm was visualized. After dissecting the neck of the aneurysm and perforators, clipping was performed.
The postoperative course was uneventful.
The surgical key points and the prospective view in approaching via the lamina terminalis and through the third ventricle for a high position basilar top aneurysm are discussed in this paper.

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Direct clipping of a giant aneurysm at the cavernous portion of the internal carotid artery (IC-GA) is very difficult because of the topographical speciality of the cavernous sinus and because of the large size of the aneurysm. There have thus been various strategies for the treatment of IC-GA.
Four cases of IC-GA have recently been treated at this hospital.
The initial sympton in all cases was an ocular problem. Neurological findings on admission showed abducens nerve palsy in two cases, oculomotor nerve palsy in one and attenuation of visual acuity in one.
A CT scan after infusion of contrast media revealed a high-density mass in three cases and a lowdensity mass with ring enhancement at the cavernous portion in another.
In these cases, a carotid artery angiogram demonstrated a giant aneurysm at the cavernous portion with a diameter of more than 25mm.
Gradual ligation of the internal carotid artery (IC) was performed with an extracranial to intracranial bypass (EC-IC bypass) in two cases and trapping of the IC with an EC-IC bypass in two other cases.
Postoperative ischemic complication developed in one case in which trapping of the IC with an EC-IC bypass was performed, but marked improvement was obtained by medical treatment.
Postoperative CT scans showed the formation of a thrombus in the cavernous portion in all cases.
Finally, the combination of the EC-IC bypass procedure with IC ligation or with a trapping of the IC seems to be a effective method of treatment for IC-GA.

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The best treatment for intracranial aneurysms is undoubtedly neck-clipping; however, some aneurysms, such as giant aneurysms or those with a broad neck, cannot be treated in this manner. The microvascular suture technique introduced by Yasargil contributed to the wide indications for curative operations of some unclippable aneurysms.
The authors present two cases of such unclippable aneurysms, which could be treated by utilizing the microvascular suture technique. The first case, a giant middle cerebral artery aneurysm, was managed with excision and end-to-end anastomosis, and the second case, an irregular shaped broadnecked aneurysm of the internal carotid artery, was treated by combining internal carotid trapping with an extracranial-intracranial bypass using an interposed saphenous vein graft. The patients had no postoperative neurological deficit. Alternative treatment is also discussed in this paper.

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A case of a giant fusiform middle cerebral artery aneurysm is presented in this paper. The aneurysm was treated with saphenous vein graft and controled occlusion of the proximal M₁ using a Drake tourniquet. Recently we have successfully employed this technique in treatment.
Case: A 27 old woman experienced a sudden onset of headaches. Examination was otherwise normal. An angiogram showed a giant fusiform aneurysm of the left middle cerebral artery. A Drake tourniquet was placed around the middle cerebral artery just proximal to the aneurysm and a saphenous vein graft was interposed between the common carotid artery and the middle cerebral artery. The next day, the tourniquet was closed with the patient awake under angiographic control. No ischemic signs were recorded during or after about 90% stenosis. One month after the operation a CT scan showed thrombosis of the aneurysm.
A prophylactic bypass in such cases is known to reduce ischemic complications. But superficial temporal artery to middle cerebral artery anastomosis is not always satisfied, so the use of the venous graft has been recommended.

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Recently combined ligation of ICA and STA-MCA anastomosis has become the treatment of choice for unclippable giant aneurysms of the ICA. However, ischemic complications have been reported in 10-25% of the cases that underwent this procedure, because of the limited flow provided by the STA-MCA bypass and of thrombo-embolic ischemia originating from the stump of the occluded ICA and thrombosing aneurysm.
An interposed long saphenous vein bypass graft was utilized between the axillary artery and the angular branch of the middle cerebral artery instead of STA-MCA anastomosis to treat a patient with an unclippable giant aneurysm of the cavernous portion of the right ICA combined with acute ligation of CCA. Ten minute manual compression of the right CCA developed neither abnormality of EEG nor ischemic symptoms. Angiography also demonstrated a good cross-filling of the ipsilateral carotid region. However, a SPECT subtraction study revealed 70% reduction of flow in the ipsilateral MCA region by manual compression of the right carotid artery. Intraoperative measurement of the flow through the vein graft was 80ml/min. CCA ligated acutely on the third postoperative day after the patency of the vein graft bypass was assured. A postoperative angiogram revealed that the giant aneurysm was thrombosed successfully. There was a good filling of the left MCA territory through the graft and ACA through the anterior communicating artery from the contralateral circulation. Thus the ICA giant aneurysm was isolated, trapped and thrombosed. The postoperative SPECT study revealed a normal CBF at rest in both hemispheres. By compressing the vein graft bypass, 60% reduction of CBF in the MCA territory was demonstrated in the subtraction image of the SPECT. A three year follow-up revealed good patency of the vein graft with no ischemic symptoms.
Acute ligation of CCA provides less chance of emboly, and a vein graft bypass from the axillary artery can provide an immediate postoperative high flow without carrying thrombi from the ICA stump. The giant aneurysm of the intracranial ICA is isolated from ipsilateral cerebral circulation. Thus, both hemodynamic and thrombo-embolic ischemia can be avoided.

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Using the detachable balloon technique, we treated two patients with inaccessible giant internal carotid aneurysms located at the cavernous and the petrosal portion.
An angiogram of the first patient, a 27 year-old female with the right trigeminal and abducens paresis revealed a giant right internal carotid aneurysm at the petrosal protion. Three days after right STA-MCA double anastomoses, intravascular surgery was performed. The internal carotid aneurysm was trapped with Debrun's No.16 and No.9 balloons placed distal and proximal to the aneurysmal neck. Following the surgery, her neurological deficit disappeared, with no repeat ischemic episode. Neuroradiological examinations showed a thrombosed right internal carotid artery with no visualization of aneurysm.
Angiogram of the second patient, a 56 year-old female with left oculomoter palsy, revealed a giani left internal carotid aneurysm at the cavernous portion. Using two Debrun's No.16 balloons, trapping of internal carotid aneurysm was performed three days after left STA-MCA anastomosis. whose anastomosis was not patent at the time of intravascular surgery. Following the trapping, transient sensory aphasia appeared. However, the oculomotor palsy gradually improved, and the aneurysm and the left internal carotid artery were found to be completely thrombosed on neuroradiological examination.
We emphasize that the trapping of the internal carotid aneurysm by the detachable balloon technique with an EC-IC bypass is the safest and most beneficial method in terms of the lesser possibility of delayed ischemic complications caused by newly developed collateral vessels to the parent artery at a site close to the aneurysm.

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Temporary occlusion test of the internal carotid artery with a balloon catheter (balloon Matas test) was performed on seven patients with cerebral aneurysms of the internal carotid artery to determine the tolerance of a permanent carotid occlusion. And, on five out of these seven patients, dynamic CT (DTC) was performed to examine the cerebral hemodynamics during balloon Matas test.
For the DCT, the Toshiba TCT-70A was used and rapid injection of amidotrizoate sodium meglumine (Urografin) was carried out. Five parameters, appearance time (AT), peak time (PT), peak height (PH), first moment effective (MT1E), and transit time (TT), were examined for DCT. The results of five patients were classified into three types according to the pattern on the findings of the balloon Matas test and of the DCT. Type 1 patients (Case 1, 2, 7) showed normal neurological signs during the balloon Matas test, and DCT findings showed a parallel shift of the time-density curve of the middle cerebral arterial territory of the occluded side compared to that contralateral to the occluded side. Functional images of PH, MT1E and TT were equal in both sides, while AT and PT were delayed in the occluded side. From the DCT findings, cerebral blood flow (CBF) is thought to have been preserved equally in both cerebral hemispheres during the carotid occlusion. Therefore, an abrupt internal carotid arterial occlusion can be performed without any trouble in this group. In type 2 (Case 3), the balloon Matas test showed no neurological deficit, but the time-density curve revealed a delay of AT and PT as well as the elongation of MT1E, TT and a decrease of PH in the middle cerebral arterial territory of the occluded side. These findings were also confirmed in the functional images. The decrease of CBF in the occluded cerebral hemisphere is suggested from the DCT findings. Therefore, extracranial to intracranial (EC-IC) bypass surgery should be recommended to prevent the ischemic insult in the future. In type 3 (Case 4), the neurological signs (disturbance of consciousness, aphasia and right hemiparesis) appeared just after the start of the balloon Matas test and DCT findings showed almost the same pattern as demonstrated in type 2 in the middle and anterior cerebral arterial territory of the occluded side. The occlusion of the internal carotid artery is contraindicated unless EC-IC bypass surgery, such as a vein graft bypass, which can supply large amount of blood flow rapidly, is performed. Our method offers reliable information to predict the risk of carotid occlusion.

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Two cases of patients with multiple peripheral aneurysms are reported; four aneurysms arising from the left callosomarginal artery feeding an arterivenous malformation (AVM) in a 51-year-old female and two aneurysms from the left posterior inferior cerebellar artery not associated with AVM in a 53-year-old female. In the former case, the AVM was partly thrombosed and the most distal aneurysm was shown to be largery obliterated in the preoperative angiography. In the latter case, the proximal aneurysm was not visualized in the preoperative angiography.

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Traumatic intracranial aneurysms are rare. Because CT has largely replaced cerebral angiography in the examination of head-injured patients, the diagnosis of traumatic intracranial aneurysm was become much more difficult. Traumatic intracranial aneurysm should be suspected when a patient has an episode of intracranial hemorrhage after a head injury.
A case of a “true” traumatic intracranial aneurysm is presented in this paper. A 9-year-old boy in a stuporous state was admitted on March 6, 1982 after a traffic accident. X-ray films demonstrated a rt. frontal linear fracture and a fracture of the rt. tibia.
A CT scan showed subarachnoid hemorrhage mainly in the interhemispheric fissure. The patient regained consciousness after 3 days of conservative treatment. Twenty-four days after admission, during rehabilitation for a rt. leg fracture, he fell down and was hit in the frontal area. He rapidly deteriorated.
A CT scan showed a large hematoma in the bifrontal lobes. An emergency craniectomy was done. During exposure, fresh arterial bleeding occurred, so an intraoperative carotid angiography was done. The angiogram showed a lt. anterior cerebral artery (A₂) aneurysm. By reopening the craniectomy, the aneurysm, which was attached to the falx and was broad based, was clipped at the base. Postoperatively he gradually improved, but mild mental change remained. Judging from the operative findings, the aneurysm was probably a “true”traumatic aneurysm. Before the operation, we misjudged the source of the hematoma as being contusion from the second head injury.
In a case of delayed or unusual intracranial hemorrhage after a head injury, cerebral angiography should be performed before surgical procedure.

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Intracranial traumatic aneurysms are one of the importment post-traumatic sequelaes. In our department we have had ten cases of intracranial traumatic aneurysm and seven cases were operated upon. The location of the aneurysms were anterior cerebral artery in four cases, middle cerebral artery in two cases and supraclinoid internal carotid artery in one case. The operative methods were trapping in five cases, neck ligation in one case, resection and neck suture in one case. Three cases had severe intraoperative rupture of the aneurysm. In all cases temporary occlusion of the parent artery and administration of mannitol were used. Operative methods and approach of these cases are discussed in this paper. Results of the seven cases were good in five and fair in two. Histological findings of aneurysmal wall were pseudoaneurysm in six cases.
Since the wall and neck of traumatic aneurysms are fragile and the danger of intraoperative rupture is very high, it is considered to be safer to occlude the parent artery temporally. Trapping and revascularization surgery before disclosing the aneurysm neck are often needed.

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Most mycotic aneurysms are bacterial aneurysms, which are caused by subacute bacterial endocarditis.
The incidences of bacterial aneurysms have been greatly reduced by the use of convenient antibiotics. Rupture of bacterial aneurysms is still one of the major causes of intracranial hemorrhage. Recently indications for surgical treatment of these aneurysms have been discussed.
On the other hand, fungal aneurysms have also been reported. Through the recent over-use of steroids, antibiotics and anti-cancer agents, the chances of opportunistic infection and fungal aneurysms have been increased.
We have had two cases of mycotic aneurysms.
Case 1 was a ruptured fungal aneurysm, which was caused by Candida. A 6-year-old boy, who suffered from chronic mucocutaneous candidiasis and granurocytopenia, was treated with Interferon and other anti-fugal agent.
After taking a bath, he suddenly lost consciousness. He was in a deep comatous state when he was carried to our hospital.
A CT scan revealed diffuse subarachnoid hemorrhage. Six days later, he died and an austopsy of the whole body was performed.
The basilar artery, the proximal part of the bilateral PCA and the lt. MCA were found to be enlarged. The diameter of the enlarged arteries was 5-7mm, and the walls were extremely thin. Saccular aneurysms were also found at the lt. IC-PC, and the prepontine segment of the lt. PCA. The lt. PCA aneurysm had ruptured at the top. Microscopic examination, showed that a thrombus had formed within the aneurysms, and Candida was spreading in the thrombus.
Case 2 was a bacterial aneurysm, which ruptured and formed intracerebral hematoma. A 42-year-old man suddenly lost consciousness and was brought to our hospital. He was semicomatous, and lt. hemiplegia, and conjugated deviation to the right was seen. A CT scan revealed intracerebral hematoma (4×3cm) in the rt. precentral gyrus, and a saccular aneurysm at the distal portion of the precentral artery was observed by the rt. CAG.
Immediate removal of the hematoma and resection of the aneurysm was performed. Antibiotics were also used for 6 weeks after the operation. After a month, angiography showed that the aneurysm had disappeared with no recurrence. Four months later, he received surgical replacement of the aortic valve. Soon after the operation he lost consciousness due to intracerebral hematoma of the lt. hemisphere. A week later, he died from another intracerebral hematoma of the rt. hemisphere. These hematomas were thought to be formed by the rupture of newly developed aneurysms.
It is generally accepted that bacterial aneurysms should be treated surgically if the aneurysm accompanies the intracerebral hematoma, or if it is single and situated distally. When the aneurysm is found around the circle of Willis, anti-biotic therapy should be chosen first, and repeated CT scan and angiography, show that the aneurysm develops in size, surgical treatment must be considered.
Therapy of fungal aneurysms is difficult. No effective treatment of a ruptured fungal aneurysm has been reported.
Mycotic aneurysms have the tendency to recur as long as a original disease which caused the bacterial or fungal emboli of the cerebral arteries has not been cured. Therefore CT scan and cerebral angiography must be checked repeatedly.

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