Aneurysms arising at the P₃ portion of the posterior cerebral artery are relatively rare. They represent 0.3%of all cases of cerebral aneurysms and 3.1%of posterior circulation aneurysms. Operative approaches to aneurysms at this portion have been reported by only a few authors.
We have experienced clipping of the aneurysm at this portion through an occipital interhemispheric approach with the patient positioned in a lateral recumbent, operated-side-down posture. We discuss the advantages and disadvantages of this approach in our current report.
An occipital interhemispheric approach has many advantages. It sacrifices less bridging veins. It makes for a more comfortable posture with a wider working space for the surgeon and assistants to carry out the operation. However, it is the disadvantage of a risk of post-operative homonymous hemianopsia.
We were careful to eliminate pressure on the striate cortex so that visual field defect could be prevented. We placed the patient with the operated side down so that the occipital lobe of the affected side subsides naturally from its own weight.

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Intracerebral hemorrhage (ICH) associated with ischemic cerebrovascular disease (ICVD) is reviewed in this paper.
We have experienced 385 cases with ICVD during the past five years, of which 11.2%were TIA, 22.1%were RIND, 53.2%were minor completed stroke, and 13.5%were major completed stroke. The follow-up period ranged from one month to 10 years (mean 1.8 years).
Episodes of ICH following ICVD occurred in 15 cases (2.0%per year). Hemorrhages were located in the putamen 7 (47%), the pons 5 (33%), and the thalamus 3 (20%).
These cases showed the following characteristic features. With regard to previous ischemic manifestations, nine cases presented RIND clinically, eight-cases demonstrated evidence of lacune on CT, 12 cases had hypertension, of which six cases responded poorly to medical treatment.
Surgical or conservative treatment resulted in a poor outcome due to the high incidence of pontine hemorrhage and large parenchymal hemorrhage. In addition, hemorrhage occurred on the opposite side to the preceding ischemic lesion, and damage over bilateral hemispheres exerted on influence on the prognosis.

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Among 365 consecutive patients with intracerebral hemorrhage, examined between March 1980 and November 1986, thirty-six cases (31 men and five women) were found to have a history of cerebral ischemic stroke. This group of patients was studied in this paper retrospectively. The mean age at the time of the hemorrhagic stroke was 62.0 and the age range was from 41 to 80.
Clinically, twenty-nine of the 36 cases had had major completed strokes, four had had vertebrobasilar insufficiencies, two had had transient ischemic strokes and one had had a progressing stroke. Thirty patients had had positive findings in computed tomography, 80%of which showed lacunar infarctions in the basal ganglia or thalamus. Angiography performed in 22 cases had revealed only five occlusive or stenotic lesions.
For the prevention of recurrent cerebral ischemia, seventeen of the 36 patients had been treated with antiplatelet drugs (APT (+) group). The other 19 cases had received neither antiplatelet drugs nor anticoagulants (APT (-) group). In the APT (+) group, 13 had had aspirin and/or trapidil, three had had ticlopidine and one had had dipyridamole.
Thirty-one patients were hypertensive[APT (+) 17; APT (-) 14]. There was one cerebral subcortical hemorrhage, and 14 putaminal, 16 thalamic, and five infratentorial hemorrhages. Especially in the APT (+) group, 16 of 17 (94%) hemorrhages were putaminal or thalamic. Dividing the volume of hematoma into “small” (<10ml), “medium” (10-30ml) and “large” (>30ml), there were eight small, six medium and three large hematomas in the APT (+) group, and 14 small, four medium and one large in the APT (-) group. The mean volume was 15.8ml in the APT (+) group and 9.6ml in the APT (-) group.
Prognosis after hemorrhagic stroke was divided into two groups: namely “good” or “poor”. In the APT (-) group, 14 patients were considered “good” and five “poor”, while only five in the APT (+) group were “good” and 12 were “poor”. The tendency was that patients of advanced age, with completed major stroke, lacunar infarction on CT scan, thalamic hemorrhage or large hematoma volume had a poor prognosis.
For the treatment and/or the prevention of cerebral ischemic strokes, many clinicians recently use antiplatelet drugs, whose efficacy, however, is not free of controversy. This report suggests that, to avoid hazardous hemorrhagic complications, meticulous care should be taken to control the blood pressure, especially in aged patients with lacunar infarction.

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Seven cases of intracerebral and intraventricular hemorrhage associated with cerebral artery occlusions are presented in this paper.
In four cases, the origin of the hemorrhage was considered to be perforated arteries. which were main collateries flows in the ipsilateral hemisphere.
Hemorrhage in the other three cases was due to the mechanism of “hypertensive ICH”.
As treatment, in four cases EC-IC bypass was performed, which was more effective in cases where the hemorrhage from collateral perforating arteries.

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Occurrence of cerebral hemorrhage and infarction in the same patient at various intervals seems to be rather rare. Among 962 cases of cerebrovascular diseases in our university hospital during a recent seven year period, including 314 cerebral hemorrhage and 300 cerebral infarction, recurrent intracerebral hemorrhage and recurrent cerebral infarction occurred in 11 cases (1.2%) and 124 cases (12.9%) respectively. On the other hand, cerebral hemorrhage and infarction in the same patient was encountered in only five cases.
Retrospective analysis of clinical data, including blood pressure, site of lesion, systemic disease,grade of arteriosclerosis, was attempted in order to make clear the underlying pathophysiology in these cases.
Additionally, arteriosclerosis of the carotid and vertebral artery was estimated as a wall Stiffness Parameter (β value) by Ultrasonic Phase-locked Echo Tracking System.
The mean age of the five patients was 64.5, which was higher than the reccurent hemorrhage group and the reccurent infarction group. All patients were male. Intracerebral hemorrhage and infarction occurred on the same side in all cases. However, hemorrhage and infarction did not occur in the same arterial territory; for instance, hemorrhage occurred in the anterior cerebral artery area and infarction occurred in the middle cerebral artery area. The time interval between the two cerebrovascular incidents was one month to seven years. Systemic hypertension was present in all cases and diabetes mellitus accompanied three cases. None of the cases had hyperlipemia.
In our extensive study on the Stiffness Parameter of carotid and vertebral arteries so far, the β value increases proportionally to the patient's age in the infarction group, as well as in the diabetic group. On the other hand, the β value in the hypertensive group was variable and definite correlation between the β value and the patient's age was not established. The β value measured in a case with hemorrhage and infarction was obviously high. Intracerebral hemorrhage and infarction had a different pathophysiological basis for their occurrence; principal pathological change in hypertensive intracerebral hemorrhage is believed to be a development of microaneurysm and fibrinoid degeneration of the artery wall. On the other hand, cerebral infarction is believed to occur as the result of arteriosclerotic narrowing of the artery. This can explain the rare occurrence of intracerebral hemorrhage and infarction in the same patient and the fact that hemorrhage and infarction developed in different arterial territories. Frequent measurements of β value of the carotid and vertebral artery may predict the occurrence of cerebral infarction, even in a patient with cerebral hemorrhage.

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In the last five years, we have experienced 340 cases of cerebral infarction, in which five cases had a recurrence of hemorrhage.
The initial infarction was recognized on the basal ganglia in three cases. It was found on the basal ganglia, the territory of the post cerebral artery, and in cerebellar hemisphere in one case each.
Four of these cases had hypertension with three cases having diabetes.
The interesting point of this study was the site of recurrent hemorrhage in these cases.
Three out of the five cases developed the hemorrhage in the cerebellar hemisphere.
Four cases developed recurrent lesions on the contralateral side from the initial infarction.
It is a well known fact that supratentorial infarction induces hypometabolism in the contralateral cerebellum. as a crossed cerebellar diaschisis.
Hypothetically, cerebellar hemorrhage secondary to contralateral supratentorial infarction might be considered a result of “crossed cerebellar diaschisis”.

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The author previously reported cerebral hemorrhage occurring in the contralateral hemisphere after cerebral infarction, and simultaneous multiple hypertensive intracerebral hematomas. In this paper, 13 such cases, mainly suffering from multiple cerebrovascular disorder complicated with cerebral hemorrhage, such as on patient who had a history of leukemia and suffered cerebral hemorrhage four times, are described. The results of monitoring intraventricular pressure during operation are also described. The case reports of three of these patients are given below.
Case 1: 64-year-old man. He had left thalamic and left cerebellar hemorrhages at the same time. This patient underwent a ventriculoperitoneal shunt operation to release occlusive hydrocephalus caused by fourth ventricular compression as a result of cerebellar hemorrhage. Although his consciousness was clear and paralysis was mild after operation, he could not eat because of the presence of bulbar paralysis and aspiration pneumonia. Using a fiber scope, excessive dilatation was found in the esophagogastric junction, and this dilatation was thought to facilitate regurgitation of gastric juice. He died from aspiration pneumonia.
Case 2: 53-year-old woman. She had diabetes and renal disease, and previously had had a right cerebrovascular disorder. At the time the author treated her, She was suffering from left cerebral hemorrhage, but her speech and motor abilities were not abated, even in the chronic stages. Therefore, her intracerebral hematoma was stereotaxically evacuated. She was discharged after abatement of symptoms.
Case 3: 54-year-old man. He had a history of leukemia. This patient suffered from hemorrhage in the right cerebral hemisphere and cerebellum four times. Therefore, we undertook stereotaxic evacuation of the intracerebral hematoma, and his symptoms were temporarily abated. However, he died from repeated aspiration pneumonia due to bulbar paralysis.
As so far described, the condition of patients with multiple cerebrovascular disorders is easily complicated by aspiration pneumonia due to pseudobulbar or bulbar paralysis. Since the dilatation occurring at the esophagogastric junction was found to be a factor in aspiration pneumonia, we should be careful of this point in management of these patients. Although patients with multiple cerebrovascular disorder are often not treated surgically because many of them are aged and is poor general condition and have severe underlying diseases, our operative monitoring of intraventricular pressure indicated that intraventricular pressure can be sufficiently decreased by minimum removal of hematoma. No marked edema was seen around the removed hematoma after surgery.
These result suggest that stereotaxic evacuation of intracerebral hematomas deserves further study in cases of multiple cerebrovascular disorder complicated by intracerebral hematoma.

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To study recurrent cerebral vascular disease, we reviewed 876 patients who had suffered cerebrovascular disease in the five years from January 1, 1981, to December 31, 1985.
Seventeen out of 330 patients with hypertensive intracerebral hemorrhage developed a recurrence of some kinds of cerebrovascular disease. The type of disease, age, number of occurrences, interval between occurrences and prognosis in these 17 cases were analysed. Risk factors for recurrence were also verified.
Twelve out of the 17 cases developed intracerebral hemorrhage again. The interval until the recurrence was most frequently less than one year; but with some cases even more than five years elapsed. Cases in which the recurrence occurred on the contralateral side were the most serious.
The prognosis was not significantly influenced by hypertension. However, hypertension with hypoproteinemia was an important prognostic factor.
The authors suggest that a high-protein diet with control of hypertension would decrease the incidence of recurrent intracerebral hemorrhage.

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Intracerebral hematoma associated with dural sinus diseases is rare. We report seven cases of intracerebral hematoma associated with dural sinus diseases in this paper.
Hemorrhage occurred in three of seven cases with dural sinus occlusion, in three of six cases with dural arteriovenous malformation, and in one of 22 cases with carotid cavernous sinus fistula.
A large intracerebral hematoma was noted in three cases and a small hematoma in four cases. The intracerebral hematomas were classified as multiple (two cases) and solitary (five cases).
In each case, hemorrhage occurred in the vicinity of subcortical, or cortical venous engorgements.
Large intracerebral hematomas with high intracranial pressure, which often occurred in sinus occlusion, showed poor prognosis, but small hematoma, which often occurred in dural arteriovenous malformation, showed good prognosis.

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Among 1,609 patients with hypertensive intracerebral hemorrhage (HIH) examined between April 1969 and October 1986 (17 years and seven months), 1,054 patients were given cerebral angiography (65.5%). Among them, 47 cases were combined with unruptured cerebral aneurysms (4.5%). Incidence of cerebral aneurysms was more frequent in the medial type (7.9%) than the lateral type (3.2%). Thirty-nine aneurysms were revealed in 30 cases receiving bilateral carotid angiography. Twenty-six of these aneurysms (66.7%) were located in the internal carotid and middle cerebral arteries at the ipsilateral side of the HIH. Surgical treatment of unruptured aneurysms was performed in 27 cases (57.4%). The operative morbidity and mortality rates were each 7.4%. Twenty cases (42.6%) were not surgically treated for their unruptured aneurysms because of severity of the HIH, complications, advanced age or severe sclerosis. Two of them (10%) died of ruptured aneurysms within three years.
Surgical indications for unruptured aneurysms should be considered carefully, especially in cases combined with HIH. The principle of treatment for unruptured aneurysms combined with HIH is as follow. Treatment of the HIH is preferred, and if surgical treatment for the HIH is needed and an unruptured aneurysms is located on the same side as the HIH, the surgical treatment of the unruptured aneurysm can be done simultaneously, or at the cranioplasty. In other cases surgery for unruptured aneurysms should be done later when the patients have resumed sufficient activity in their daily lives and have no severe complications.

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A total of 347 patients who were hospitalized at the Department of Neurosurgery, Shizuoka Saiseikai General Hospital between September, 1980 and September, 1986 due to intracerebral hemorrhage, were used as subjects in this study, excepting those with subarachnoid hemorrhage caused by intracranial aneurysms and arteriovenous malformations, hemorrhagic infarction and ventricular hemorrhage of undeterminable origin. Out of the 347 patients, 26 had recurrent intracerebral hemorrhage at a different site from that found at the initial attack; seven who had a history of intracerebral hemorrhage were hospitalized due to recurrent hemorrhage; 19 who had been hospitalized due to the initial intracerebral hemorrhage suffered recurrent intracerebral hemorrhage. Among 13 patients having a history of putaminal hemorrhage, five, four, three and one had recurrent hemorrhage in the contralateral putamen, subcortex, thalamus and in the pons, respectively. Among seven patients with previous hemorrhage in the thalamus, four, two and one again developed hemorrhage in the contralateral thalamus, putamen and subcortex, respectively. Two each of four patients having had cerebellar hemorrhage were again attacked with hemorrhage in the putamen and thalamus, respectively. Recurrent hemorrhage occurred in the subcortex and putamen respectively in two patients with previous subcortical hemorrhage. Out of the 26 patients having intracerebral hemorrhage in different sites at different times, recurrent hemorrhage was found on the contralateral side in 19. These patients were 17 men and 9 women.
The mean age at the time of initial hemorrhage was 55.6 and that at the second time was 57.8. The duration between the first and second hemorrhage ranged from one month to 15 years, about 3 years on average. The complication which was most frequently seen was hypertension. Out of 15 patients with hypertension complications, 13 had been continuously treated from the time of the initial hemorrhage until the occurrence of second hemorrhage. Although only four of the 26 patients previously underwent cerebral angiography of the recurrent regions, no evidence indicating an anticipation of hemorrhage was found. As for surgical treatment, eight underwent hematoma removal through cerebrostomy and six underwent ventricular drainage at the time of initial hemorrhage. At the time of the recurrent hemorrhage, hematomas were removed in six cases, and ventricular drainage was applied to four; only one patient underwent the removal of hematomas at both times. Out of the 26 patients with recurrent hemorrhage, three were suffering their third hemorrhage, and hemorrhage had occurred four times in one patient, in a different site each time. As with those stated in previous reports, the prognosis of recurrent intracerebral hemorrhage is poor from the standpoints of both life and function.

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There are reports that recurrent carotid stenosis after carotid endarterectomy though incidence of symptomatic carotid restenosis is less than 5%. Although various operative approaches have been attempted for recurrent carotid stenosis, a patch graft with a saphenous vein has been generally adopted. However, reoperation is technically more difficult because of the loss of normal anatomic planes, scar tissue involvement of adjacent nerves, and lack of cleavage plane requiring sharp dissection of the lesion.
Recently, the authors performed a carotid-subclavian artery bypass with interposition saphenous vein grafts and proximal ligation of the internal carotid artery for recurrent stenosis of the common carotid artery with good results.
The patient, a 58-year-old male, was admitted because of progressive hemiparesis and speech disturbance. About two years ago, he had undergone an endarterectomy for stenosis of both common carotid arteries.
A carotid artery angiogram showed restenosis of the left common corotid artery and regional cerebral blood flow examination by ¹³³Xe also showed decreased blood flow in the left hemisphere. So, carotid-subclavian artery bypass with interposition saphenous vein grafts and proximal ligation of the the internal carotid artery were performed. Postoperatively, his hemiparesis and speech disturbance improved gradually.
A postoperative subclavian artery angiogram demonstrated a patent bypass with excellent filling of the intracranial artery through the bypass.

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One of the characteristics of occlusive cerebrovascular disease in Japan is a high frequency of involvement of the extracranial and intracranial vessels (tandem lesion). This study involved 18 patient with tandem lesions who had a carotid endarterectomy (CEA).
Besides carotid bifurcation stenosis and/or ulcer on the side corresponding to the ischemic symptoms, the sites of other angiographic lesions were: contralateral carotid bifurcation stenosis or occlusion, 11; ipsilateral carotid siphon stenosis, 9; contralateral carotid siphon stenosis, 3; ipsilateral middle cerebral artery stenosis, 3; and vertebrobasilar artery stenosis or occlusion, 2. The mean followup period was 2.9 years.
Following superficial temporal artery-middle cerebral artery bypass surgery three patients developed new ischemic symptoms responsible for the asymptomatic ulcerative lesion of the carotid bifurcation, which was improved by CEA. One patient had a minor stroke three years after CEA because of recurrent stenosis and another revealed a progression of an asymptomatic carotid stenosis without any neurological aggravation; however, these two patient were uniformly relieved of symptoms with the use of anticoagulant agents. Thirteen other patients not only demonstrated no symptomatic deterioration but also no angiographic worsening.
The high incidence of resolution of intracranial stenosis or occlusion during the period of study indicates that surgery should not be contemplated until a sufficient interval has elapsed to exclude the chance of recanalization. The resolving carotid siphon stenosis following CEA and changes in intracranial stenotic lesions after extracranial-intracranial (EC-IC) bypass are well known; therefore, we would recommend CEA when the unilateral stenosis of the carotid artery appears to be more severe than the ipsilateral intracranial stenosis. In cases with unilateral carotid bifurcation stenosis and contralateral internal carotid artery occlusion or siphon stenosis, CEA is highly effective in patients with symptoms resulting from carotid bifurcation stenosis. Patients with symptoms referable to the side of the occluded internal carotid artery or siphon stenosis with poor collateral pathways may benefit from EC-IC bypass. CEA following EC-IC bypass may also be indicated for the contralateral asymptomatic carotid bifurcation ulcerative lesion.

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Since 1978, the authors have performed stereotactic evacuation in about 300 cases of hypertensive intracerebral hemorrhage using Komai's CT-stereotactic apparatus. We experienced 24 cases of hypertensive pontine hemorrhage from 1979 to 1986; 10 cases treated surgically by sterotactic approach (surgical group, 1983~1986) and 14 treated non-surgically (non-surgical group, 1979~1986). The present paper reports our experience with ten patients with pontine hemorrhage treated by the stereotactic aspiration using Komai's CT-stereotactic apparatus. The paper also tries to evaluate the usefulness of our surgical procedure, comparing the CT findings and the outcome between the two groups.
Our stereotactic aspiration procedure is simple and can be done safely under local anesthesia without any complications. Approximately 83.6% of the hematoma volume was evacuated and the disturbed consciousness and respiration of most of the patients improved in the early postoperative days.
The most important factor affecting the outcome of the treatment was the transverse diameter of the hematoma. With hematomas of 22 to 30mm in diameter, the surgical group exceeded the nonsurgical group in recovery (p<0.05). With hematomas of less than 22mm and those of more than 30mm in diameter, there was no statistical difference in the outcome between the two groups. Concerning the location of the hematoma, the patients with unilateral type hematomas resulted in a good outcome in the surgical group (p<0.05). Those with the bilateral type of hematoma revealed poor outcome in both groups.
We, therefore, conclude that the stereotactic approcch is recommended for a patient with the unilateral pontine hemorrhage whose diameter is 22 to 30mm.

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Clinical application of noninvasive imaging of the extracranial carotid arteries was compared using real-time B-time Doppler and angiography (including DSA). Two hundred eighty-nine ultrasonograms (152 patients) were performed.
B-mode ultrasonography permitted the identification of several characteristic findings of plaques. There were several types of plaque: (1) homogeneous (2) heterogeneous (3) sonolucent (4) hyperchoic (5) others (skip plaques spotty plaque, etc.)
Overall accuracy was 84.3% in 127 carotid arteries. Correlation between B-mode Doppler and angiography is relatively good, but accuracy in complete occlusion and/or severe stenosis was rather low. Even relatively small plaque was apt to be found by B-mode Doppler imaging. The noninvasive ultrasonography examination is very a useful method of evaluating carotid artery disease, especially, in older patients or in postoperative follow-up of carotid surgery.

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Two cases of dural arteriovenous malformation (dAVM) with a vascular sac at the dilated pial vein as a drainer are reported in this paper. The dAVM were located at the anterior cranial fossa in Case 1 and at the petrous portion in Case 2. Both cases had intracranial hemorrhage and, especially in Case 1, the associated vascular sac was thought to be the source of the hemorrhage, for its location was the same as the small intracerebral hematoma. The relationship between the intracranial hemorrhage and cortical drainage are discussed in the paper. The importance of blockade of cortical drainage and occlusion or removal of nidus is stressed for protection against intracranial hemorrhage.

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Two successfully treated adult cases of intra-ventricular hemorrhage (IVH) accompanied with middle cerebral artery (MCA) occlusion, moyamoya phenomenon, pseudoaneurysm at the peripheral portion of the dilatated anterior choroidal artery (AchA) and choroid plexus angioma are reported in the paper.
In each case, CT scan on admission revealed IVH with a small intracerebral hematoma (ICH) adjacent to the trigonal portion of the right lateral ventricle; and an initial right carotid angiogram showed occlusion at the proximal portion of the right MCA with moyamoya vessels around it and angiomatous shadow at the trigonal portion of the right lateral ventricle. In the first follow up angiogram (14 days after onset in Case 1 and 21 days after in Case 2) an aneurysm appeared at the peripheral portion of the dilatated AchA in each case and had grown larger by the time of the second follow up angiogram (49 days after onset in Case 1 and 40 days after in Case 2). In each case, surgery was performed and both the aneurysm and the angiomatous mass were removed. Histologically the former was diagnosed as a pseudo-aneurysm and the latter was diagnosed as an AVM.
Recently many cases of aneurysms associated with moyamoya diseases and moyamoya-like disease have been reported. Moyamoya phenomenon is not specific to moyamoya disease. Arterial occlusion due to various causes, i. e., arteriosclerosis, radiation, tumor, neurofibromatosis, and spontaneous occlusion, may cause the formation of moyamoya vessels as a collateral pathway.
In the literature, 27 cases (including our two cases) of moyamoya phenomenon associated with MCA occlusion have been reported. Of the 27 cases, 16 presented intracranial hemorrhage (IVH:11 cases, ICH: three cases, SAH: two cases). Of these 16 cases, seven had intracranial aneurysms, and in six of these aneurysms were located within the moyamoya vessels. All of the six cases presented IVH. These cases seemed to be similar to moyamoya disease associated with aneurysms located within the moyamoya vessels.
We considered our two cases as follow: Moyamoya vessels associated with spontaneous MCA occlusion seemed to be formed as a collateral pathway. Dilatation of the AchA developed as a collateral pathway and a feeding artery to the choroid plexus angioma. ICH and IVH occurred due to rupture of the dilatated fragile wall of the moyamoya vessels and a pseudoaneurysm was formed at the site of the ICH. Choroid plexus angioma may have facilitated an increase in blood flow of the AchA and participated in the rupture.
As to the treatment of such cases, EC-IC bypass surgery in addition to removal of the aneurysm has been reported. But the effect of EC-IC bypass has not been elucidated clearly and should be investigated carefully in the future.

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